
Class _ 

Book 



COPYRIGHT DEPOSIT 



LIST OK CONTRIBUTORS. 



BARTLEY, ELIAS II., B.S., M.I). 
BROWNING, WILLIAM W . M.D.,LL.B. 
BUCKMASTER, AUGUSTUS II.. M.I). 
CAMERON, J. CHALMERS, M.D. 
CHAPIN, HENRY DWIGHT, M.D. 
DAVIS, EDWARD P., M.I). 
DICKINSON, ROBERT L., M.D. 
EDGAR, JAMES CLIFTON, M.D. 
ETHERIDGE, JAMES H., M.D. 
HAMILTON, ALLAN McLANE, M.D. 
HENROTIN, FERNAND, M.D. 
JEWETT, CHARLES, A.M., M.D. 
MANTON, W. P., M.D. 
PALMER, CHAUNCEY D., M.D. 
ROBB, HUNTER, M.D. 
VAN COTT, JOSHUA M., Jr., M.D. 
YINEBERG, HIRAM N., M.D. 
WEBSTER, J. CLARENCE, M.D. 
WILLIAMS, J. WIIITRIDGE, M.D. 



Messrs. Lea Brothers & Co., intend 
this book to be sold at the advertised 
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terms which will not allow of discount 



THE 



PRACTICE OF OBSTETRICS 



BY 



AMERICAN AUTHORS 



EDITED BY 

CHARLES JEWETT, M.D., 

PROFESSOR OF OBSTETRICS AND DISEASES OF CHILDREN IN THE LONG ISLAND COLLEGE HOSPITAL, 

NEW YORK. 



ILLUSTRATED WITH 441 ENGRAVINGS, 34 OF WHICH ARE IN 
COLORS, AND 22 COLORED PLATES. 




LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA. 

1899. 



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2.3483 



Entered according to the Act of Congress in the year 1899, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



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PREFACE. 
— ±'t 

This volume is the work of obstetric teachers and of others equally 
expert in the cognate lines on which they have written. It aims to be 
a clear and practical treatise suited to the needs of medical classes and 
also to furnish in moderate compass a concise and comprehensive guide 
"or the practitioner. 

The Editor takes this opportunity of thanking the able corps of Con- 
tributors for their cooperation in the work. He is particularly indebted 
for illustrations to Professor Farabeuf, and his acknowledgments are 
due Drs. H. F. Jewett, C. F. Craig, and H. P. de Forest for 
valuable assistance, the latter having prepared the index. 

C. J. 



(v) 



LIST OF CONTRIBUTORS 



ELI AS H. BARTLEY, B.S., M.D., 

Professor of Chemistry and Toxicology in the Long Island College Hospital ; 
late Lecturer on Diseases of Children in the Long Island College Hospital; 
Physician to the Sheltering Arms Nursery, New York. 

WILLIAM W. BROWNING, LL.B., A.M., M.D., 

Professor of Anatomy and Clinical Professor of Orthopedics in the Long Island 
College Hospital ; Orthopedic Surgeon in the Bush wick Hospital, New York. 

AUGUSTUS H. BUCKM ASTER, M.D., 

Professor of Gynecology and Obstetrics in the Medical Department, University of 
Virginia, Charlottesville. 

J. CHALMERS CAMERON, M.D., CM., M.R.C.P.I., 

Professor of Midwifery and Diseases of Infancy in the McGill University, Mon- 
treal, Canada. 

HENRY DWIGHT CHAPIN, M.D., 

Professor of Diseases of Children in the New York Post-Graduate Medical School 
and Hospital ; Attending Physician to the Post-Graduate, the Willard Parker, 
and the Riverside Hospital ; Consulting Physician to the Randall's Island 
Hospital, New York. 

EDWARD P. DAVIS, M.D., 

Professor of Obstetrics in the Jefferson Medical College ; Professor of Obstetrics 
and Diseases of Infancy in the Philadelphia Polyclinic; Obstetrician to the 
Philadelphia Hospital, etc., Philadelphia. 

ROBERT L. DICKINSON, M.D., 

Instructor in Obstetrics and Assistant Obstetrician in the Long Island College 
Hospital; Obstetrician to the Kings County Hospital ; Surgeon (Gynecologist) 
to the Brooklyn Hospital, New York. 

J. CLIFTON EDGAR, M.D., 

Professor of Obstetrics and Clinical Midwifery in the Cornell University Medical 
College ; Attending Physician to the Lying-in Hospital and to the Maternity 
Hospital, New York. 

JAMES H. ETHERIDGE, M.D., 

Professor of Obstetrics and Gynecology in the Rush Medical College ; Professor of 
Gynecology in the Chicago Polyclinic; Attending Gynecologist in the Presby- 
terian Hospital; Consulting Gynecologist in St. Joseph's Hospital, Chicago. 

(vii) 



\ 111 



LIST OF CONTRIBUTORS. 



MA.W M. 1 \\i: II \.MlI.To\. M ,D .. 

I *i- > t . — rof Mental Diseases in the Cornell University Medical College ; Consult- 
ing Physician to the Manhattan State Hospital for the Insane, New fork. 

II i:\ \\h HENROTIN, M.I»., 

Profi gynecology in Ihe I bicago Polyclinic; Gynecologist to St Luke's, 

St Joseph's, and the German Bospital, chic:!-". 

< II IRLES .11 W ETT, LM., M.D., Sc.D., 

Professor of Obstetrics and Diseases of children in the Long [sland College Hos- 
pital ; Obstetrician to the Hospital; Consulting Obstetrician to the Kings 
County Hospital ; Consulting Gynecologist to the Bushwick Hospital; Con- 
sulting Physician to St Christopher's Hospital, etc., New York. 

W'ALlT.k P, M ANTON. M.D., 

Professor of Clinical Gynecology and Adjunct Professor of Obstetrics in the 
Detroil < allege of Medicine; Gynecologist to the Harper Hospital, the Eastern 
and Northern Michigan Asylum for the Insane, and St. Joseph's Retreat, 
Detroit 

CHAUNCEY D. PALMER, M.D., 

Professor of ( tynecology and Clinical Gynecology in the Medical College of Ohio; 
t i\ necological and Obstetric Clinician at the Cincinnati Hospital, Cincinnati. 

HUNTER ROBR, M.D., 

Professor of Gynecology in the Medical Department of the Western Reserve 
University ; Gynecologist to the Lakeside Hospital, Cleveland. 

JOSHUA M. VAX COTT, Jr., M.D., 

Professor of Pathology in the Long Island College Hospital ; Pathologist to the 
Long Island, the Brooklyn, and the Kings County Hospital, New York. 

HIRAM N. YINEBERG, M.D., 

Attending Gynecologist to the St. Mark's Hospital and the Montefiore Home for 
Chronic Invalids ; Gynecologist to the Mt. Sinai Hospital, Out-door Department, 
New York. 

J. CLARENCE WEBSTER, B.A., M.D. (Edin.), F.R.C.P.E., 

Lecturer on Gynecology, McGill University; Assistant Gynecologist, Royal 
Victoria Hospital, Montreal; late Senior Assistant to the Professor of Mid- 
wifery and Diseases of Women in the University of Edinburgh. 

J. WHITRIDGE WILLIAMS, M.D., 

Associate Professor of Obstetrics in the Johns Hopkins University, Baltimore. 



CONTENTS. 



PART I. 
ANATOMY. 

CHAPTER I. 

PAGE 

The Female Pelvic Organs— The Mammary Glands 17 

By William W. Browning, M.D. 



PART II. 
PHYSIOLOGY OF PREGNANCY. 

CHAPTER II. 

Menstruation — Ovulation — Development of the Ovum ... 73 
By Walter P. Manton, M.D. 

CHAPTER III. 

Changes in the Maternal Organism Caused by Pregnancy . . 119 
By Chauncey D. Palmer, M.D. 

CHAPTER IV. 

Diagnosis of Pregnancy 128 

By Robert L. Dickinson, M.D. 

CHAPTER V. 

Duration of Pregnancy— Evidence of Previous Pregnancy. . 150 
By Chauncey D. Palmer, M.D. 

CHAPTER VI. 

Hygiene and Management of Pregnancy ...... 153 

By Chauncey D. Palmer, M.D. 

(ix) 



x CONTENTS. 

PA RT I II. 
PH V> I OLOG V F LA BOR. 

< II A PT E B VII. 

PAGE 

Tin: Mechanical Elements of Labob \'>7 

By < Ihables .' bwett, M.D. 

(II \ PT EB V I II. 
Tin: Mechanism and Clinical Course of Normal Labor . , . 192 

By AUGUSTUS II. BUCKMASTEB, M.D. 

CIIA PTER IX. 

Tin. Management of Normal Labor 211 

By Charles Jewett, M.D. 



PART IV. 
PHYSIOLOGY OF THE PUERPERIUM. 

CHAPTER X. 

Tin: PrERPERAL State and its Management — The Care of the 

Puerperal Woman 247 

By Hunter Robb, M.D. 

CHAPTER XI. 

The New bobn Child and its Management 265 

By Elias H. Babtley, M.D. 



PART V. 
PATHOLOGY OF PREGNANCY. 

CHAPTER XII. 

Multiple Pregnancy . . , 295 

By Walter P. Manton, M.D. 

CHAPTER XIII. 

Anomalies and Diseases of the Fcetal Appendages .... 299 
By James H. Etheridge, M.D. 



CONTENTS. xi 

CHAPTEE XIV. 

PAGE 

Pathology of the Fcetus— Anomalies of the Fcetus . . . 312 

By Joshua M. Van Cott, Jr., M.D. 

CHAPTER XV. 

Pathology of the Fcetus: Continued — Diseases of the Fcetus . 327 
By Joshua M. Van Cott, Jr., M.D. 

CHAPTER XVI. 

Abortion and Premature Labor 335 

By Hiram N". Vineberg, M.D. 

CHAPTER XVII. 

Ectopic Gestation 355 

By Fernand Henrotin, M.D. 

CHAPTER XVIII. 

Diseases of Pregnancy 387 

By James H. Etheridge, M.D. 



PART VI. 
PATHOLOGY OF LABOR. 

CHAPTER XIX. 

Anomalies of the Mechanism — Anomalies of the Expellent 

Forces 399 

By J. Chalmers Cameron, M.D., and J. Clarence Webster, M.D. 

CHAPTER XX. 

Anomalies of the Mechanism: Continued — Anomalies of the 

Passages— Anomalies of the Fcetus 409 

By J. Chalmers Cameron, M.D., and J. Clarence Webster, M.D. 

CHAPTER XXI. 

Anomalies Arising from Accidents or Disease 481 

By James H. Etheridge, M.D. 

CHAPTER XXII. 

Anomalies Arising from Accidents or Disease: Continued — The 

Hemorrhages 498 

By James H. Etheridge, M.D., and Charles Jewett, M.D. 



rfj C0NTENT8, 

(ii v pt i: i; xxii i. 

ANOMALIES ARISING i HOW ACCIDENTS OB DISEASE: CONTINUED — 

ECLAMPSLA 517 

r.> J. Cliftom Edgar, m.d. 

( II a PTEB X XIV. 

Anomalies Arising prow Accidents ob Disease: Continued — Dia- 

i;i i rs Cardiac Disease 548 

By James h. Etheridqe, M.D. 



PART VII. 
PATHOLOGY OF THE PUERPERIUM. 

CHAPTER XXV. 

Anomalies and Diseases of the Breasts and Nipples . . . 547 
By J. M. Van Cott, Jr., M.D. 

CHAPTER XXVI. 

Puerperal Insanity 555 

By Allan McLane Hamilton, M.D. 

CHAPTER XXVII. 

Puerperal Infection , 562 

By J. Whitridge Williams, M.D. 

CHAPTER XXVIII. 

Malformations, Injuries, and Diseases of the New-born Child . 606 
By Henry Dwight Chapin, M.D. 



PART VIII. 
OBSTETRIC SURGERY. 

CHAPTER XXIX. 

The Immediate Repair of Vaginal and Vulvar Lacerations — 

Immediate Repair of Lacerated Cervix 629 

By Hunter Robb, M.D. 



CONTENTS. xiii 

CHAPTEK XXX. 

PAGE 

The Induction of Abortion and of Premature Labor — Retained 

and Adherent Placenta 641 

By Hunter Robb, M.D. 

CHAPTER XXXI. 
The Forceps 655 

By Charles Jewett, M.D. 

CHAPTER XXXII. 

Version . 680 

By Edward P. Davis, M.D. 

CHAPTER XXXIII. 

Embryotomy 708 

By Edward P. Davis, M.D. 

CHAPTER XXXIV. 

Cesarean Section— The Porro Operation— Symphysiotomy . . 722 
By Hunter Robb, M.D. 



< 




A 







PLATE I. 

1, internal pudic artery; 2, 3, inferior hemor- 
rhoidal ; 4, transverse perineal ; 5, superficial per- 
ineal (vulvar); 6, common trunk dividing into 7, 
8, 9; 7, branch to body of clitoris; 8, artery to the 
bulb; 9, dorsal artery; 10, n, 12, 13, 14, internal 
pudic nerve and branches ; /j, anastomotic branch 
to 16, pudendal branch of 17, small sciatic nerve ; 
/8, terminal branches forming nervous sheath for 
clitoris; 19, terminal branch of the ilio-inguinal 
nerve. 

A, anus; C, clitoris; M, meatus urinarius ; 
L, great sciatic ligament; V, vagina; O, coccyx; 
T, tuberosity of the ischium. 

a, gluteus maximus muscle; b, sphincter ani 
externus; c, ischio-coccygeal band of levator ani 
muscle ; d, transversus perinei muscle ; e t bulbo- 
eavernosus muscle ; g, erector elitoridis muscle ; 
h, portion of perineal muscle ; /, adductor magnus 
muscle; k, gracilis muscle. 





















u 



I 



PART 1. 

ANATOMY. 



CHAPTER I. 

THE FEMALE PELVIC ORGANS. 

The female organs concerned in reproduction are located in the pelvis. 
They are usually classified as external and internal. The external organs 
include the nions Veneris, the labia majora, the labia minora, the clitoris, 
and the vaginal orifice. To them collectively is applied the designation 
pudendum. The term " vulva " includes all of the external organs except 
the mons Veneris. The internal organs are the vagina, the vaginal bulbs, 
the uterus, the Fallopian tubes, and the ovaries. The ovaries are con- 
cerned in germination, the tubes in fecundation, the uterus in gestation, 
and the remaining organs in copulation. 

The terms " external" and "internal," as applied to the organs of 
generation, have no scientific value. They are retained merely for con- 
venience of description. (Plate I.) 

The Perineal Space. If the female be placed upon the back, with the 
legs flexed and the thighs flexed, abducted, and rotated outward, the 
perineal space will be exposed. Its landmarks may be made out by 
palpation. They are the tip of the coccyx, the subpubic arch, and the 
tubera ischiorum. From the pubic arch to the tuberosity of the ischium 
upon each side the boundary is bony. It consists of the descending 
ramus of the pubis and the ramus of the ischium. From the tuberosity 
of the ischium to the coccyx the boundary is an imaginary line. It 
corresponds, approximately, to the lower border of the gluteus maximus 
muscle. It should be observed that the gluteal fold does not coincide 
with this border, as is sometimes stated. 

The Mons Veneris. Above the subpubic arch is an elevated mass of 
tissue, triangular in outline. The apex of the triangle points toward the 
perineal space; the base is marked by a fold of skin extending trans- 
versely across the hypogastrium; the sides correspond with the folds of 
the groins. This is the mons Veneris, or mount of love. It might more 
properly be termed the mons pubis. The skin over the mons pubis is 
thick. After puberty it is covered with a growth of coarse, curly hair, 
of a color somewhat darker than that upon the scalp. Underlying 
the skin is a quantity of areolar tissue continuous with the superficial 
fascia of the abdomen, of the thighs, and of the labia majora. It differs 
from the fasciae in those regions, however, in possessing greater firmness 
and elasticity — qualities imparted to it by fibrous bands or trabecule, 

2 (17) 



1 g ANATOMY, 

oontaining a oertain proportion of elastic elements, by which it Is trav- 
ersed. The tnone pubis serves a purely mechanical purpose, and is of 
interest to the obstetrician as a landmark only. 

The Perineum. In the median line of the perineal space appears the 
anus and the cleft of the vulva. They arc about *2.r> em., 1 inch, apart 
The area between the amis and the vulva is, by obstetricians, <1< signated 
the perineum. The skin here is thin, deeply pigmented, and marked by 
a median raphe along w hich it is closely adherent to the underlying struc- 
tures. A raphe, less noticeable, may also be observed extending from 

the anUS to the COOOyX. The skin in this situation is not so deeply pig- 
mented nor so closely adherent to the underlying structures as i> that 
over the perineum. 

For convenience of description the perineal area is divided by an 
imaginary transverse line into an anterior, genito-urinary, region, and a 
posterior, ischio-rectal, region. The dividing line is drawn across the 
perineum joining the tubera ischiorum; it presents a slight coneavity 
toward the aims. 

The Labia Majora. Flanking the cleft of the vulva (rima urogenital}*) 
are the labia majora. Together they are analogous to the scrotum in the 
male. At the nions pubis they meet, constituting the anterior commte- 
surr. Below they merge into the skin of the perineum. To the skin 
of the perineum limiting the cleft of the vulva, the name posterior com- 
missure has been improperly applied. Each labium may be compared 
to a three-sided pyramid. The base is continuous with the mons pubis; 
the apex is at the perineum; one surface rests upon the pubic ramus, one 
looks outward toward the thigh, and one looks inward toward its fellow 
of the opposite side. The outer surface is convex. It is covered with 
coarse skin, over which extends the growth of hair from the nions pubis. 
The inner surface is also covered with skin, but of a different character. 
It is thin and moist and of a reddish color. It is covered with a growth 
of downy hair, to be seen upon close inspection only. Underlying the 
skin of tlie labium majns is a fascia containing fat. The fat is abundant 
near the nions, but diminishes toward the perineum. Continued into the 
fascia from the superficial fascia of the perineum is a stratum of elastic 
tissue. This may be traced as far as the margin of the external abdom- 
inal ring. Comparing this fascia with the dartos in the male, some 
anatomists claim to have demonstrated in it the presence of involuntary 
muscular fibres. By reason of the presence of the elastic and the mus- 
cular (?) elements in the superficial fascia, the skin of the labium may 
present a corrugated appearance. 

The round ligament of the uterus, after emerging from the external 
abdominal ring, is usually lost in the adipose tissue of the mons. It 
may extend into that of the labium. In some cases, though rarely, it 
carries with it a fold of peritoneum. The course of a pudendal hernia 
is thus accounted for. 

At birth there is a slight gaping of the labia majora owing to their 
incomplete development. In the well-nourished adult virgin they are 
usually in contact (vulva connivens), concealing from view the structures 
within. In the aged and emaciated they may gape (vulva hians), owing 
to waste of adipose tissue. They may be pressed apart by excessive 
development of the nymphse. 



THE FEMALE PELVIC ORGANS. 

Fig. 1. 



19 




1. Vulva of non-parous woman, closed - 
3. Vulva of parous woman, closed. 



2. Vulva of non-parous woman, open. 
4. Vulva of parous woman, open. 






ANATOMY 



The Labia Minora. By separating the labia majors the labia minora or 
nympha may be brought into view. They are analogous to the skin of 
the penis in the male. Each nympha consists of an elongated triangular 
fold of modified integument. The bases unite medially above the clitoris 
and the apices are lost in the labia majora at the sides of the ostium 
vaginae. Each presents two surfaces and a free border. In the undis- 
turbed condition of the parts the external surface is in contact with the 
labium majus of it- own side, and the internal surface is in contact with 
the corresponding Burfaoe of the opposite nympha. At the glans clitori- 
dis the free borders bifurcate. The upper divisions unite above that 







External organs of generation. (Browning.) 
1. Corpus clitoridis. 2. Pneputium clitoridis. 3. Glans clitoridis. 4. Frenulum. 5. Labium majus. 
6. Labium minus. 7. Vestibulum. 8. Meatus urinarius. 9. Vagina. 10. Hymen. 11. Fossa navicu- 
laris. 12. Fourchette. 

structure, forming a hood-like covering for it, known as its prmputium, 
and the lower divisions unite below it, constituting its frcenu lam. The 
surfaces of the nymphce are smooth and moist. Sebaceous glands exist 
upon the external surfaces, but hairs are nearly if not quite wanting. 
Upon the internal surfaces there are no hairs, and few if any sebaceous 
glands. A peculiar cheesy material known as smegma collects beneath 
the prepuce and upon the opposed surfaces of the labia minora. It is 
not a true sebaceous secretion, but is composed principally of cast-off 
pavement epithelium cells. 



THE FEMALE PELVIC ORGANS. 21 

The underlying fascia of the nympha contains no fat, but supports a 
plexus of veins. 

The labia minora, as has been already stated, are visible at the cleft 
of the vulva in the newborn. In the adult virgin they are pink in color, 
uniform in size, have uuindented borders, and are concealed from view 
in the undisturbed position of the parts. From frequent copulation, and 
especially by childbearing, they undergo great changes in shape and 
appearance. They may assume a bluish color and become pigmented. 
They may become uuevenly elongated and lobulated, and may protrude 
from between the greater labia. They may also lose their resemblance 
to mucous membrane and present the appearance of true integument. 

The Fourchette. If the labia majora be widely separated, a transverse 
band of skin appears just above the posterior commissure. This is the 
fourchette or frcenulum pudendi. When thus demonstrated, a boat-like 
depression is artificially created between it and the ostium vaginae. To 
this has been given the name fossa navicularis. Curiously enough, 
Quain and other well-established authorities describe the fossa navicularis 
as located between the fourchette and the posterior commissure. There 
seems, also, to be a difference of opinion as to the histology of the four- 
chette. Lusk, Skene, and others, following the conclusions of Luschka, 
describe it as the posterior commissure of the nymphse. Commonly it is 
described as a transverse band derived from the labia majora. This 
discussion, however, is of more interest to the anatomist or medical jurist 
than to the obstetrician, since the integrity of the fourchette rarely sur- 
vives the first parturition. 

Vessels and Nerves of the Pudendum. The labia majora and the labia 
minora receive their vascular supply from the superficial perineal branches 
of the internal pudic arteries. These branches are larger than the cor- 
responding vessels in the male, but they follow similar courses. Each 
branch arises from the parent trunk near the tuber ischii. It runs along 
the ramus beneath the superficial perineal fascia to the labium, where it 
anastomoses with the pudic branch of the femoral artery. 

The veins of both the labia majora and the labia minora form rich 
plexuses which communicate freely with those of the vaginal bulbs. 
They empty by trunks which accompany the arteries above named. 
Those of the nymphse are firmly supported by elastic and by smooth 
muscular tissue. They become turgid during sexual excitement. They 
do not, however, as is sometimes erroneously stated, constitute an erectile 
tissue. The veins of the labia majora are more loosely supported. They 
frequently present troublesome varicosities during pregnancy. They 
communicate with the veins of the round ligament of the uterus. 

The lymphatics of the vulva empty for the most part into the inguinal 
glands. A few in the neutral territory between the nymphse and the 
vagina may find their way to the femoral chains. 

The nerve-supply of these structures is from the internal pudic and the 
lesser sciatic nerves. The former accompany the arteries of the same 
name. As they become superficial in the upper part of the perineal space 
they inosculate with the inferior branches of the lesser sciatic nerves. 
Peripheral filaments are richly supplied to the prseputium clitoridis, which 
is regarded by some writers as the seat of voluptuous sensation. 

The Vestibule. The separation of the labia minora discloses a space in 



L »_> ANATOMY. 

which may be Been the orifice of the vagina (introitus or ostium vagina). 
The space Ie lozenge-shaped. Above it is bounded by the nymphse aa 
they converge and unite at the fronulum clitoridis. Below it is flanked 
by the labia majora aa they meel at the posterior commissure. The 
ostium vaginas is in the lower half of this space. Between it and the 
posterior commissure are the fossa oavicularis and the fourchette. The 
Bpaoe above the anterior margin of the vaginal opening is triangular in 
..inline. Some observers claim to have discovered a distinct line of 
demarcation between the modified skin of the nymphae and the mucous 
Lining of the genito-urinary tract. Though difficult of ocular demon- 
stration, such a dividing line undoubtedly exists. Jt is described as fol- 
lowing the attached border of the internal surfaces of the nymphae, 
cr.)— in- beneath the frenulum clitoridis above and skirting the posterior 
margin of the ostium vaginae below. To the portion of the space thus 
bounded, anterior to the ostium vaginae, is given the name vestibule. 
With the labia majora in their usual position it forms a gutter leading 
from the clitoris to the vagina. From this fact its name is obtained. 
The propriety of the designation has been questioned, but without good 
reason, it would seem. The floor of the vestibule is marked by faint 
transverse ridges. For this and other reasons it may be regarded as a 
continuation forward of the anterior vaginal wall. 

The Meatus Urinarius. In the median line of the vestibule, within 1 
cm., .'. inch, from the vaginal orifice and about 2.5 cm., 1 inch, from the 
clitoris, may be observed the opening of the urethra. Its site is marked 
by an elevation of mucous membrane. This is more prominent ante- 
riorly and has been accepted as a guide for passing the catheter by the 
sense of touch. As a result of frequent coition, and especially after 
parturition, this landmark is so far obliterated as to render it of doubt- 
ful value as such. The puckering of the mucous membrane about the 
urethral opening is caused by the presence of nnstriated muscular fibres. 
A ring of such tissue has been described by Luschka surrounding the 
ostium vaginae and the urethra, which is here embedded in the anterior 
vaginal wall. To it has been given the name sphincter vaginae. Near 
the meatus urinarius may be seen the openings of several large mucous 
crypts. They are the alandulce vestibuli minores. They may be so large 
a- to admit the tip of a catheter. Otherwise the mucous membrane of 
the vestibule resembles that in other parts of the body. 

The Hymen. The vaginal orifice varies in appearance in different indi- 
viduals. In the virgin it is partially closed by a structure known as 
the hymen. The hymen is a reduplication of the most inferior portion of 
the vaginal walls. It, therefore, consists of connective tissue supporting 
bloodvessels and covered by mucous membrane. Elastic and muscular 
tissue as well as nerve-fibres may be demonstrated within it. As a rule, 
it springs from the posterior and the lateral vaginal walls only. In 
exceptional cases the anterior wall contributes also to its formation. It, 
therefore, presents a variety of forms. (Fig. 3.) It may completely 
occlude the vagina {imperforate). It may be perforated by numerous 
small openings (cribriform). It may present a central longitudinal cleft. 
[ta common form, however, is crescentic, the free concave border looking 
toward the anterior vaginal wall. Being crowded inward, it lies in folds, 
giving to it a fluted appearance. 



THE FEMALE PELVIC ORGANS. 



23 



Usually the hymen is more or less lacerated at the first coitus. (Fig. 
4.) Almost without exception it is obliterated at parturition. There- 
after nothing remains of it but fleshy tags attached about the entrance 
to the vagina. (Fig. 5.) These are called carunculce myrtiformes. 
From the medico-legal stand-point the absence of a hymen furnishes 



Fig. 3. 




CRESCENTIC 



FRINGED BILABIAL BIPERFORATE 

Different forms of hvmen. 



CRIBRIFORM 



prima facie evidence only of sexual indulgence. The converse of this 
proposition is also true. It may be absent in the virgin, and has been 
known to persist in the parous woman. On the other hand, carunculae 
myrtiformes are undeniable evidence of a former parturition. 



Fig. 4. 



Fig. 5. 





Hymen after parturition. 
Meatus urinarius. OV. Vaginal orifice. H. Hymen. 



Hymen after coitus. 

Fig. 4.— C. Clitoris. PL. Xymphse. 
Rent in hymen. 

Fig. 5. — U. Meatus urinarius. P. Nympha. CM. Carunculse myrtiformes. Z. Portion of hymen, 
detached and floating. D. A tear through the fourchette. 



When the hymen is intact the exposed ostium vaginae appears as a 
vertical slit. AVhen it is destroyed the anterior and posterior vaginal 
walls are seen to be in contact. The remains of the hymen, however, 



24 



ANATOMY. 



may be traoed abort the orifioe in a ring, which is laterally coin])!'. 
as the vulva is allowed to close. This form of the ostium vaginas is 
maintained, no doubt, by the arrangement of the muscular fibres of the 
peh ic floor. 

The Glans Clitoridis. Jusi above the apex of the vestibular triangle 
may be seen the glans olitoridis surrounded by its prepuce. Those 
whose knowledge of this structure has been gained by reading the descrip- 
tions ordinarily given in the text-hooks will be much disappointed in its 
appearance. In the non-turgid condition it is a mere papilla. Fre- 
quently it is entirely hidden from view by an elongated prepuce. Occa- 
sionally the prepuce is adherent to it, rendering it still more difficult of 
demonstration. When turgid during sexual excitement it is rarely as 
large a- a -mail pea. 

The glans is the <>nlv part of the clitoris which is visible on inspection 
of the genitalia. It is covered by a modified skin which is extremely 
delicate and sparingly supplied with sebaceous glands. Sebaceous glands, 
however, are well developed about its circumference, and secrete an oily 
substance which emits a characteristic odor. 

The Clitoris. The clitoris is not the analogue of the penis, as is so often 
stated. It corresponds rather to the glans, corpora cavernosa, and crura 
of that organ. When erect it may be felt, like a rounded cord, about 
2.5 cm., 1 inch, in length and 5 mm., i inch, in diameter. It arches 

Fig. 6. 




The clitoris. 

A. Bulbus vestibuli. C. Pars intermedia. E. Glans clitoridis. F. Corpus clitoridis. 

H. Dursal vein. L. Right cms. M. Vestibule. N. Gland of Bartholin. 



upward from the apex of the vestibular triangle to the summit of the 
subpubic arch. (Fig. 6.) It consists of glans, corpora cavernosa, and 
crura, in structure similar to the corresponding parts of the penis, but 
of diminutive size. The trabecular of the cavernous bodies are firmer 



THE FEMALE PELVIC ORGANS. 25 

than those in the male organ. The glans is imperforate and is formed 
of a plexus of veins continued into it from the bulbs of the vagina. It 
will be noticed that the corpora cavernosa are formed of true erectile 
tissue. Not so the glans, though it becomes turgid during the erection 
of the clitoris. 

The clitoris, like its analogue, is furnished with a suspensory ligament. 
Its mobility, however, is greatly limited by the attachments of the pre- 
puce and of the frenulum. 

The vessels supplying the clitoris are disposed in the same manner as 
the corresponding ones in the male. The same may be said of the lym- 
phatic canals. The nerve-supply to the organ is proportionately much 
more abundant than that of its analogue. Its source is both from the 
internal pudic nerves and from the hypogastric plexus of the sympathetic. 
Nerves from both these sources communicate freely in the organ and 
form an especially rich network upon the glans. Their method of termi- 
nation is similar in both sexes. 

The Anus. About 2.5 cm., 1 inch, below the posterior commissure of 
the vulva appears the anus. It is the orifice of the bowel. The skin 
about the anus is exceedingly delicate and deeply pigmented. It is 
abundantly supplied with sebaceous glands and covered with a growth 
of hair. The hair does not grow as profusely, however, as in the male. 
The skin of the anus is prolonged into the bowel about 1 cm., ^ inch. 
Owing to the presence in it of unstriated muscular fibres, it is thrown 
into radiating folds and presents a puckered appearance. To the mus- 
cular fibres has been given the name corrugator cutis ani. 

The subcutaneous veins at the junction of the skin and the mucous 
membrane of the bowel are loosely supported. For this reason they 
frequently present varicose enlargements and protrude as external piles. 
The remains of these tumors may persist about the anus in the form of 
fleshy tags. 

The Pelvic Flook. 

The pelvic floor consists of the skin, the fascia, and the connective 
tissue closing in the pelvic outlet, together with certain specialized bands 
of muscular fibres. It supports the pelvic viscera, none of which nor 
any part of the peritoneum should be considered as belonging to the 
floor itself ; it is perforated by the rectum and by the vagina; in the 
anterior wall of the latter canal is the lower end of the urethra. The 
anatomy of ihe rectum and of the vagina will be considered later. They 
are musculo-membranous canals, the orifices of which have already been 
described as being about 2.5 cm., 1 inch, apart. Within the pelvis the 
canals approach so that their walls come in contact at about 4 cm., 
1J inch, from their orifices. 

It may be well to remind the reader that the body is for the most 
part developed in symmetrical halves. There exists, therefore, a line 
of union between the lateral halves, and this is usually located in the 
median plane. Instead of speaking of the structures upon one side of 
this line as continuous with corresponding ones upon the other, it would 
be more nearly correct to speak of both as meeting in a median raphe. 
Inasmuch as vessels and nerves as they approach their terminations 



2(J 



l \.l TOMY. 



diminish in Bize, it follows that the median raphe ifl Least vascular and 
least sensitive, | Fig. 7. | 

The External Sphincter Ani Muscle. The -kin and the fascia extending 

from tli«' ami- t<> the ooocyjs arc closely adherent along the raphe. 

ther they constitate the ano-coccygeat ligament. From each side of 

FlO. 7. 




Muscles of the pelvic floor. (Modified, from Savage.) 
A. Auus. B. Bulbs of the vestibule. C. Coccyx. G. Glans clitoridis. U. Meatus urinarius. V. 
Vagina. D. Glands of Bartholin, a. Ischio-cavernosus muscle. 6. Bulbo-cavernosus. c. Trans- 
versa perinei. d. Sphincter ani. e. Levator ani. /. Coccygeus. g. Gluteus maximus. h. Obtu- 
rator externus. 

this baud or ligament, beneath the superficial fascia, thin, pale sheets of 
striated muscular fibres arise. They pass forward to blend with those 
of other muscles at the central point of the perineum, thus surrounding 
the anus elliptieally. With deeper fibres derived from the pubic bands 
of the levator ani muscles they constitute the sphincter ani externus muscle. 
The function of the external sphincter is to keep the anus closed in 



THE FEMALE PELVIC ORGANS. 27 

response to the will during violent muscular exertions, such as coughing, 
sneezing, and the like. It forms a point d'appui for the other muscles of 
the perineum, and may aid in expelling the feces at the end of the act 
of defecation. Loss of its function does not of necessity result in incon- 
tinence of feces. The deep fibres derived from the levatores ani pass 
posteriorly to the anus. Traction upon them separately everts the anus. 

The Superficial Fascia of the Perineum. The superficial layer of the 
superficial fascia of the anal and that of the genito-urinary regions are 
continuous with each other and with that of the rest of the body. In 
the genital area of the perineal space a deep layer of the superficial fascia 
may be demonstrated. It corresponds to Colles' fascia in the male. It 
is attached to the anterior margins of the descending rami of the pubes, 
and is continued upon the rami of the ischia as far as the tuberosities. 
Toward the central line it enters the labia majora, and in them may be 
traced to the external abdominal rings. Posteriorly it turns around the 
transversus perinei muscles to join the deep fascia. The deep fascia, 
otherwise known as the anterior or inferior layer of the triangular liga- 
ment, will be described hereafter. 

To expose the remaining muscles of the perineum the deep layer of 
the superficial fascia must be removed. 

The Constrictor Vaginae Muscle. The constrictor vaginos muscle (some- 
times also called the sphincter vaginae) is the analogue of the accelerator 
urinse or bulbo-cavernosus in the male. It exercises no such function 
as its name would suggest, but rather compresses the bulbs of the vagina, 
which it covers. The muscle consists of thin sheets of striated fibres 
located upon the sides of the vaginal opening which it thus surrounds. 
The fibres arise at the perineal body, being closely related to those of 
the external sphincter ani and of the transversus perinei muscles. Pass- 
ing over the vaginal bulbs they converge somewhat and are inserted into 
the sheaths of the corpora cavernosa in front of the insertions of the 
erector clitoridis muscles. A slip crosses the clitoris and compresses the 
dorsal vein. It is claimed by Henle that some fibres may be traced into 
the posterior surfaces of the vaginal bulbs and some into the floor of the 
vestibule. The constrictor vagina? muscle is separated by a considerable 
interval from the vaginal walls. 

The Transversus Perinei Muscles. The transversus perinei or ischio-hul- 
bosus muscles correspond to those of the same name in the male. They 
differ in that they are relatively smaller in the female. Each muscle 
arises from the inner surface of the ramus of the ischium just above the 
tuberosity and between the origins of the obturator internus and the 
erector clitoridis muscles. It is inserted into the base of the perineal 
body. The fibres intermingle at their insertion with those of the other 
muscles meeting at this point, A few fibres deeply situated are inserted 
in the vaginal wall and some join their fellows from the opposite side in 
front of the urethra. These latter are sometimes separately named the 
deep transversus perinei muscles. 

The Erector Clitoridis Muscles. Internal to the origins of the trans- 
versus perinei muscles and somewhat nearer to the tuberosities of the 
ischia arise the erector clitoridis or ischio-cavernosus muscles. They are 
of reduced size as compared with their analogues, the erectores penis. 
As its name indicates, each is inserted into the corpus cavernosum. It 



28 



i.\.i TOMY. 



Is also inserted into the Buspensory ligament In its course it lies near 
thf ramus of the ischium and the descending ramus of the pubis. 

The Perineal Ledge. In the triangular intervals left upon cadi side 
between the three last-described muscles may be seen the deep fascia of 
the perineum. As bas been already stated, it is also called the anterior 
or infi rior layer of the triangular ligament. It consists of a sheet of fascia 
attached Laterally to the ischiatic and the pubic rami and anteriorly to 
the pubio arch Posteriorly to the transversa perinei muscle- it unites 
with the deep layer of the superficial fascia. At their line of union 
these fasciee are joined by the fascia lining the under surfaces of the 
levator atii muscles. Th us is formed the perineal ledge. The inferior 
or anterior layer of the triangular ligament is perforated by the vagina 
and the urethra, between which canals it sends a slip across the vesti- 
bule. It is, for this reason, a much weaker structure in the female than 
in the male. 

Fig. 8. 




The bulbs of the vestibule. 

a. Bulb of vestibule. 6. Muscular tissue of vagina, c, d, e,f. The clitoris and muscles, g, h, i, k, I, m, n. 

Veins of the nyinphae and clitoris communicating with the epigastric and obturator veins. 



The Bulbs of the Vagina. Located at the sides of the vagina are the 
vagi ad I bulbs, more commonly designated the bulbs of the vestibule. 
(Fig. 8.) They are analogous to the bulbous portion of the corpus 
spongiosum in the male. They lie between the constrictor vaginae 
muscle and the anterior layer of the triangular ligament. Relying upon 
the usual illustrative drawings, one would certainly be disappointed in 
their appearance, unless an artificially injected specimen were to be 
examined. Each bulb consists of a plexus of large veins enclosed 
within a fibrous capsule. When injected it is about 2.5 cm., 1 inch, in 
length and 12 mm., J inch, at its greatest breadth. It is flask-shaped, 



THE FEMALE PELVIC ORGANS. 



29 



the bottom of the flask being on a line with the points where the labia 
minora disappear at the sides of the ostium vaginae. Anteriorly the 
bulbs taper and communicate with each other beneath the clitoris. The 
isthmus of communication is known as the pars intermedialis of Kobelt. 
The veins of the bulbs communicate freely with the plexuses of the 
nymphse and of the labia majora, and also with those making up the 
substance of the glans clitoridis. 

The bulbs of the vagina, though becoming turgid during sexual excite- 
ment, do not constitute a true erectile tissue. When turgid they encroach 
upon the space between the pubic rami, and thus narrow the vaginal 
orifice. 

The Pelvic Fasciae. An almost complete partition exists between the 
superficial structures of the pelvic floor and the viscera of the pelvis. 
It is formed by sheets of fascia and by the levator ani and coccygeus 
muscles. Since its lateral halves are symmetrical, but one side will be 
described. 




Coronal section of the pelvis. 
A. Ilium. P. Ischium. C. Acetabulum. D. Psoas magnus muscle. E. Obturator externus. F. 
Levator ani. G. Sphincter ani externus. a. Transversalis fascia. 6. Iliac fascia, c. Obturator 
fascia, d. '■' White line." e. Recto-vesical fascia, f. Alcock's canal. 



The obturator internus muscle arises from the lateral pelvic wall. It is 
attached to all but a small portion of the lower part of the obturator mem- 
brane. It has also a bony origin from the ramus of the ischium and the 
descending ramus of the pubis contiguous to the obturator foramen and 
from the bodies of the ischium and of the ilium. From this extensive 



30 



J.V.I TO MY. 



origin its fibres converge to a tendon which Leaves the pelvic through the 
lesser sciatio foramen. The piriformis muscle arises from the antero- 
lateral aspect of the Bacrum and passes ou< of the pelvis tlirough the 
greater sciatio foramen. 

The Obturator Fascia is continuous with the iliac fascia and with that 
covering the pyriformis muscle. Above it looks toward the pelvic cavity 
and below it form- the external boundary of the ischio-rectal fossa. 
Prom this fascia a leaflet is given off, which takes a direction transversely 
to the pelvis. 1 1 is designated the 

Recto-vesical Fascia, or vesical layer of the pelvic fascia. The line of its 
attachment to the obturator fascia is the so-called white line. The course 



Fig. 10. 




Sagittal section of the pelvis. 

S. Symphysis. P. Perineal ledge. 1. Superficial layer of the superficial fascia. 2. Peep layer of the 
superficial fascia (Colles' fascia in the male). 3. Anterior layer of the triangular ligament. 4. Pos- 
terior layer of the triangular ligament. 5. Recto-vesical fascia. 

It is to be understood that these planes of fascia are perforated by the urethra, the vagina, and the 
rectum. 

of the white line may be traced from the spine of the ischium to the pos- 
terior surface of the body of the pubis in an arc the convexity of which 
is downward. The lowest point of the arc is a little more than 5 cm., 
2 inches, below the pectineal line. By some anatomists that portion of 
the fascia covering the obturator interims muscle below the white line 
only is designated the obturator fascia, that above being described as 
part of the pelvic fascia. 

The recto-vesical fascia meets its fellow from the opposite side in a 
median raphe. Here it is perforated by the rectum and by the vagina, 
in the anterior wall of which is the lower part of the urethra. It may 
be traced into the walls of these canals. Webster has separately described 
the portion between the bladder and the vagina, that between the vagina 



THE FEMALE PELVIC ORGANS. 



31 



and the rectum, and that posterior to the rectum as the vesico-vaginal, the 
recto-vaginal, and the rectal layers respectively. The following is taken 
also from the same author : £ - Further, the arrangement of the visceral 
[recto-vesical] fascia in the anterior part of the pelvis is of considerable 
importance. Here the visceral [recto-vesical] layer arising from the 
back of the lower part of the pubis on each side of the middle line above 
the point of origin of the anterior fibres of the levatores ani as well as 
the attachment of the parietal [obturator] fascia passes backward as two 
strong bands above them and on each side of the urethra, to become 
blended with the anterior surface of the bladder. These are the anterior 
true ligaments of the bladder. Between them is a space filled with loose 
connective tissue and fat, continuous below with the retro-pubic fat and 
above with the suprapubic or retro-peritoneal fat." 

Just external to the anterior true ligaments, as above described, por- 
tions of the recto-vesical fascia are reflected upon the bladder as its lateral 
true ligaments. 

Fig. 11. 




Drawing from a cast of a dissection made at the Long Island College Hospital. (Browning.) 
1. Rectum. 2. Coccyx. 3. Labium minus. 4. Sphincter ani externus. 5. Fibres of the levator ani 
arising from the os pubis. 6. Fibres arising from the triangular ligament. 7. Fibres arising from the 
" white line." 8. Fibres arising from the spine of the ischium. 

The Superior or Posterior Layer of the Triangular Ligament. From the 
obturator fascia along its attachment to the ramus of the ischium and to 
the descending ramus of the pubes a fascia is derived which meets its 
fellow in the median line. It is superficial to the levator ani muscle and 
blends with its sheath. In the middle line it is continued into the sheath 
of the vagina and unites with the recto-vesical fascia. By union with 
the corresponding structure of the opposite side a triangular sheet is 
formed which is perforated by the vagina and the urethra. Its apex is 
at the subpubic arch and its base joins the anterior or inferior layer of 



32 



ANA TOMT. 



the triangular Ligament at the perineal Ledge. To this structure, weak 
in character, baa beeu given the name superior or posterior layer oj the 
triangular ligament* 

The Levator Ani Muscle. Underlying (t. <•., superficial to) the recto- 
vesical fascia is the levator ani muscle. Respecting its origin anatomists 
are practically agreed, bul the direction of its fibres and their insertion 
has been variously described. It arises from the intrapelvic surface of 
the body of the os pubis and from the posterior layer of the triangular 
Ligament, from the spine of the ischium and from the whole length of 

Fig. 12. 




Drawing from a photograph of a dissection made at the Long Island College Hospital. (Browning.) 
1. Symphysis. 2. Coccyx. 3. Anus. 4. Superficial fibres from the pubic origin of the levator ani. 
5. Deeper fibres from the pubic origin. 6. Fibres from the " white line." 7. Fibres from the spine of 
the ischium. 8. Gluteus maximus muscle. 



the white line. The fibres arising from the pubis, those from the white 
line, and those from the ischium are sufficiently distinct as to their arrange- 
ment and as to their insertion to entitle them to separate description if 
not to entitle them to be considered separate muscles. The area of pubic 
origiu is located about 12 mm., J inch, from the symphysis and 3.5 cm., 
1 \ inch, below the upper border of the bone. The fibres arising here 
are joined by those from the posterior layer of the triangular ligament. 
This latter structure blends with the obturator fascia along the descend- 



THE FEMALE PELVIC ORGANS. 



33 



ing pubic ramus. It will thus be seen that the origin of the pubic 
portion of the levator is more extensive than usually described and that 
its plane is superficial to and intersects that of the portion arising from 
the white line. The fibres, arising as above described, soon gather to 
form a band, about 12 mm., J inch, wide and 3 mm., ■£■ inch, thick, and 
distinctly separable from the rest of the muscle. It takes a course nearly 
horizontally backward toward the anus. At its insertion it is bilaminar. 
The superficial fibres are continued into the sphincter ani externus, of 
which they become a part. Of the deeper fibres a few turn forward into 
the perineal body. By far the greater number take a backward course. 
Posterior to the rectum they come in close contact with their fellows from 
the opposite side, but do not join them, as is sometimes stated, either 
with or without the intervention of tendon. Most can be traced to the 
coccyx, though some fall short thereof, ending in the sheath of the muscle. 
As the pubic band sweeps by the vagina it is 5 mm., J inch, distant there- 
from. A few stray fibres from its lowermost origin, by no means con- 
stant, cross above the band and terminate in the vaginal wall. They 
correspond to the levator prostata? in the male. 



Fig. 13. 




Drawing from a photograph of a dissection made at the Long Island College Hospital ; individual 

fibres of the levator isolated. (Browning.) 
1. Symphysis pubis. 2. Coccyx. 3. Anus. 4. Deep fibres from pubic origin. 5. Fibres from fascial 
origin. 6. Fibres from ischial spine. 7. White line. 8. Gluteus maximus muscle. 



The fibres from the ischium arise from the inner aspect of the spine 
contiguous to and just in front of the coccygeus muscle. They form a 
spindle-shaped bundle, thicker, somewhat more superficial than, and dis- 
tinctly separable from the fibres of fascial origin. They may also be 
distinguished by their darker color. The course of the bundle is nearly 
transverse, and it is for the most part inserted into the fourth coccygeal 
segment. A few superficial fibres turn forward upon the recto-coccy- 
geal raphe. 

The portion of the levator intermediate between those already described 
is thin and membranous. It consists of a number of fascicles which 

3 



:;i 



ANATOMY. 



arise from a fascia weakly attached to the white line. Even in well- 
developed women the fascicles exhibit fascial intervals. In the aged 
and emaciated they undergo a marked degree of atrophy and degenera- 
tion. Their direction i> downward, backward, and inward with varying 
obliquity toward the rectum and the rectococcygeal raphe. The anterior 
are the most oblique and the posterior arc nearly transverse. A- they 
approach the rectum and the raphe they turn backward and course in a 
direction nearly parallel with the median line; most of them reach the 
coocyj : some become aponeurotic before doing bo. 

The onlii reason why all the fibres of the levator ani muscle forming the 
deeper layer of the pubic band and all those arising from the " white line" 
do not reach the coccyx, but some of them become aponeurotic before doing 
so, is because the levator in the human subject belongs to the class of rudi- 
iik ntary muscles. 

Fig. 14. 




Drawing from a photograph of the dissection of the pelvis of a young priroipara just after parturition. 

The levator ani cleaned and intrapelvic pressure removed. (Browning.) 

1. Symphysis. 2. Coccyx. 3. Anus. 4. Tuberosity of the ischium. 5. Fibres from pubic origin. 

6. Fibres from "white line." 7. Fibres from the spine of the ischium. 



The levator ani muscle is lined by a thin fascia which adheres closely 
to it. It is known as the anal fascia. On the other hand, it can be 
readily dissected from the recto-vesical fascia. When thus dissected a 
delicate fascia may be demonstrated upon the upper surface of the muscle. 
This with the anal fascia constitutes its sheath. In the median line, 
extending from the rectum to the coccyx, the sheath of the levator ani 
muscle blends with the recto-vesical fascia forming the recto-coccygeal 
raphe. At the perineal body also and at the sides of the vagina and of 
the rectum these structures blend. This has led some authors to erro- 
neously describe the levator as inserted into the walls of the rectum and 
of the vagina. 

The recto-vesical fascia constitutes a support for the pelvic contents. 
By the contraction of the levatores ani this support is raised and the 
pelvic viscera elevated. The post-vaginal structures are also drawn for- 



THE FEMALE PELVIC ORGANS. 35 

ward. A very noticeable result of traction upon the pubic band is to 
evert the anus. 

Those who have conducted investigations upon the lower animais will 
have observed the proportionately greater development of the levator 
ani in those possessed of a tail, and that its function in such animals is 
almost entirely to act upon that structure. 

The triangular interval between the posterior border, of the levator 
ani muscles and the anterior border of the pyrif ormis is filled in by the 
coccygeus. This is a thin muscular sheet. It arises from the spine of 
the ischium, and, spreading out fan-shaped, is inserted into the side of 
the coccyx and of the sacrum adjoining. 

Savage, in his description of the pelvic floor, gives to the pubic portion 
of the levator the name " pubo-coccygeus ;" to the rest of the muscle the 
name " obturato-coccygeus," and to the coccygeus the name " ischio- 
coccygeus." 

The Perineal Body. It is unfortunate that the term "perineum," 
when treating of the female, is used somewhat ambiguously. By anato- 
mists it is applied without distinction of sex to the whole perineal area. 
By obstetricians and gynecologists it is, as a rule, applied only to that 
span of tissue intervening between the anus and the posterior commissure 
of the vulva. This source of coufusion is not cleared up by designating 
this latter area "the perineum proper." "What obstetricians call the 
perineum or perineum proper corresponds to the central tendinous point 
in the male. 

Fig. 15. 




The external genitals, as seen in mesial section. (Henle.) 



a. Anus. 6. Perineal body. c. Vagina, d. Urethra, e. Labium minus. /. Clitoris, g. Fossa navicu- 
laris, in front of which is the hymen. 

It has already been shown that underlying the skin and the superficial 
fascia of this limited space several muscles intermingle their fibres. 
They are the sphincter ani externus, the constrictor vagina?, and the 
trau versus perinei. By the union of the deep layer of the superficial 
fascia and the deep fascia of the perineum (anterior layer of the trian- 
gular ligament) a strong resisting band (the perineal ledge) is formed. 
This stretches between the tuberosities of the ischia, and in crossing meets 
the anterior limit of the external sphincter ani muscle. These structures 
oieetiog at the ceutral point of the perineum, together with the areolar, 



ANATOMY. 

elastic and involuntary muscular tissue disposed between and about them, 
form the larger and by far the most important pari of what has been 
designated the /» rineal body. 

It has already been stated thai the rectum and the vagina, though 
opening at a distance from each other of 2.5 cm., 1 inch, come in 
contact at about 1 om., 1 ! inch, from their orifices. The perineal 
body is the aggregation of tissues Included between these canals below 
their contact. 1 1 is usually described as triangular in outline upon sagittal 
section and pyramidal in form. When the rectum and the vagina are 
flaccid it is gourd-shaped rather than pyramidal. The tissues forming 
its expanded portion or base have been already described. So much of 
the body as lie- above the pelvic fascia does not differ essentially in struc- 
tural character from the connective tissue disposed elsewhere among the 
intrapelvic viscera. 

The Ischio-rectal Fossa. The ischio-rectal fossa in the female is broader 
and shallower than in the male; otherwise the anatomy of both is the 
same. Its form is pyramidal. It is bounded anteriorly by the perineal 
Ledge, externally by the obturator fascia, and superiorly and internally 
by the anal fascia. It contains firm, coarse areolar tissue of low vascu- 
larity and, on that account, is frequently the seat of abscesses. This 
region is of practical interest to the obstetrician in so far only that in 
very fat women it may obstruct delivery. 

It should be remembered that terminal branches of the pudic arteries 
and nerves approach the anus from before backward, crossing the external 
sphincter obliquely. 

The Rectum. The rectum is that part of the intestinal tract which 
extends from the pelvic brim to the anus. At its commencement it lies 
upon the left sacro-iliac synchondrosis. Throughout its course it pre- 
sents three well-marked curves. It first curves downward, backward, 
and toward the right to the hollow of the sacrum. Thence it curves 
forward to reach and to become attached to the posterior vaginal wall. 
It then leaves the vagina, from which it is separated in the rest of its 
course by the perineal body. The three curves are in length 9 cm., 7.5 
cm., and 4 cm. respectively. The entire length of the canal is, there- 
fore, about 20.5 cm., 8 inches. The rectum when empty occupies little 
of the pelvic space, but is capable of great distention. When distended 
at the time of parturition it may present an obstacle to delivery. Its 
most dilatable part is about 2.5 cm., 1 inch, above the anus, and is desig- 
nated the ampulla. The portion extending from the ampulla to the anus 
is sometimes described as the anal canal. 

The coats of the rectum are muscular and mucous and are united by 
submucous tissue. The mucous and submucous structures are similar to 
those of the colon, except that the former is more vascular. In the 
mucous coat may be distinguished two strata of unstriped fibres. The 
fibres of the external stratum are longitudinally disposed and uniformly 
distributed about the canal. The fibres of the internal stratum encircle 
the whole of the tube. About the anal canal, down to the external 
sphincter ani, the circular fibres are augmented, so as to form a band 4 
mm., jr inch, in thickness, and 18 mm., J inch, in width. This consti- 
tutes the internal sphincter ani muscle. When the rectum is empty its 
anterior and posterior walls above the anal canal are in contact. Except 



THE FEMALE PELVIC ORGANS. 



37 



Fig. 16. 



when artificially distended or during defecation the anus is closed by 
tonic contraction of the internal sphincter. 

Attention should be called to certain folds of the mucous coat not 
dissimilar to the valvuhe conniventes in the small intestine. Of these 
there are three which have been designated the 
valves of Houston. (Fig. 16.) They are ar- 
ranged transversely or obliquely to the lumen 
of the tube, and remain unobliterated when it 
is distended. The longest of them (plica trans- 
versalis recti) projects into the rectum from 
the right. It is about on a level with the 
cul-de-sac of Douglas. The two others pro- 
ject from the left wall. They are about 5 
cm., 2 inches, apart and equally distant above 
and below the plane of that upon the opposite 
side. Feces may become impacted above 
these folds, which fact led Hyrtl to desig- 
nate them u the third sphincter." 

The hemorrhoidal veins are especially 
abundant in the submucosa. They commu- 
nicate freely and empty into both the general 
and the portal circulation. In pelvic obstruc- 
tion or congestion they may undergo varicose 
enlargement, and constitute internal piles. 

The upper third of the rectum is completely 
invested by peritoneum. This is reflected 
upon it from as low down as the third sacral 
segment. The fold of membrane thus formed 
is denominated the meso-rectum. Anteriorly the 
peritoneum descends upon the rectum to within 6 cm., 21 inches, of the 
anus, whence it is reflected upon the vagina. Thus is formed the recto- 
vaginal pouch, or cul-de-sac of Douglas. 

The upper part of the rectum lies upon the pyriformis muscle and the 
sacral plexus of nerves. It has to its left side the left ureter and the left 
internal iliac artery. Below its peritoneal investment it is united to the 
sacrum and the coccyx behind, and to the levator ani muscles laterally, 
by areolar tissue. 

The Bladder. The bladder is a hollow muscular organ lined with 
mucous membrane. It is more or less intimately connected to surround- 
ing parts by dense fibrous or by loose areolar tissue. In structure and 
function it does not differ in the sexes. It will be necessary in a work 
of the scope of this to call attention only to certain peculiarities of 
form in the female bladder and to such relations as are of interest to the 
obstetrician. Its capacity is stated to be somewhat less than that of the 
male bladder, though, under some circumstances, it is more distensible. 
It is interposed between the symphysis pubis in front and the uterus and 
the vagina behind. The neck surrounds the urethral opening. It, as a 
rule, is the most dependent portion of the organ when the erect position 
of the body is assumed. The circular muscular fibres are here augmented 
somewhat, and the mucous membrane presents a puckered appearance. 
To the reinforced circular fibres has been given the name sphincter vesical. 




Rectum inflated. (Chadwick.) 
a, b. Sphincter tertius. c. Ampulla. 






ANATOMY. 



Tlii- name, however, is misleading, since there exists here no true sphinc- 
ter. The term "neck" is also unfortunate in the description of the 
bladder, for the reason thai the entrance of the urethra is abrupt and 
not gradual. The uvula is less distinct and the trigone is smaller than 
in the male bladder. The triangle, at the angles of which are located 
the urethral opening and the ureteric orifices, is more nearly equilateral. 



each leg measuring about 3.5 cm., 



\\ inch. 



FIG. IT. 




Sagittal section of the female pelvis. 

At a variable distance above the pnbic bone the peritoneum is reflected 
from the anterior abdominal wall to the summit of the bladder. The 
space under this membrane and between the anterior bladder-wall and 
the pubes is known as the cavity of Retzius. It is occupied by a mass of 
loose areolar tissue which allows considerable mobility to the viscus. 



THE FEMALE PELVIC ORGANS. 



39 



Posteriorly the bladder is connected with the upper part of the vagina 
and with the cervix uteri by a firmer connective tissue. From the 
summit of the bladder the peritoneum is reflected upon the uterus at 
about the level of the os internum, forming the vesico-uterine pouch. 

When empty the bladder sinks below the pelvic brim and the fundus 
of the uterus falls forward upon it. The vesico-uterine pouch is then 
collapsed and the intestines rest upon the posterior uterine wall. When 
distended the bladder rises into the abdominal cavity. It carries the 
uterus upward and pushes it backward, and coils of intestine may fall 
into the vesico-uterine pouch. 

The distended bladder of the adult female is ovoid, the long axis being 
transverse. That of the child and that of the aged assume more nearly 
the masculine type. When empty the bladder sinks beneath the pelvic 
brim and the uterus drops forward upon it. Upon sagittal section the 
long axis of the collapsed bladder would form nearly a right angle with 
that of the vagina. 



Fig. 18. 




x. Plane of pelvic outlet, y. Plane of pelvic inlet. 1. Symphysis. 2. Sacrum. 3. Rectum. 4. 
Uterus. 5. Vagina. 6. Bladder. 9. Sigmoid flexure of the colon. 10. Utero-sacral ligament. 

The Urethra and the Urethro- vaginal Septum. The urethra of the female 
is about 3.5 cm., 1 J inch, in length. Its axis is nearly parallel with the 
plane of the pelvic brim. Its lower three-fourths is embedded in the 
anterior vaginal wall. Its upper fourth is separated therefrom by a 
mass of cellular tissue. The average diameter of the canal is 5 mm., 
J inch, though it is very dilatable. Its walls are muscular and lined 
with mucous membrane. The mucous membrane is thrown into longi- 
tudinal folds by the presence of elastic fibres in the submucosa. The 
muscular wall consists of two distinct strata of smooth fibres. Those of 
the internal stratum are longitudinal in direction, continuous with the 
longitudinally disposed fibres of the bladder. The external stratum is 
continuous with the sphincter vesicas. In the upper fourth of the urethra 
the external fibres encircle the canal. In its lower three-fourths they 
may be demonstrated anteriorly to it only, being continuous posteriorly 
with the circular fibres of the vagina. The striated fibres from the deep 
transversus perinei muscles which meet in front of the urethra are some- 
times described as the compressor urethrce or Guthrie's muscle. Some 



40 



ANA TOMT. 



investigators olaim to have demonstrated the presence of voluntary fibres 
encircling tin- upper pari of the canal, which they contend act asa vol- 
untary Bpninoter. The arrangement of the Bphincter vagina of Luschka, 

whereby the urethra is i ipressed againsl the urethro-vaginal septum 

has already been alluded to. 

The urethrovaginal septum maybe nearly or quite L.5 cm., h inch, 
in thickness in the lower three-fourths. Above, the canals are more 
widely separated by the interposition of cellular tissue. An idea of 
the relative position of the parts, as well as of the thickness of the 
septum, may be gained from the following statement : If a Hue be drawn 
from the middle of the posterior surface of the symphysis pubis to the 
cervix uteri, its length would be about 5 cm., 2 inches, and the vesical 
opening of the urethra would be located at about the union of the ante- 
rior and middle thirds. Quain states that the female urethra corresponds 
to the prostatic portion in the male. There seems, however, to be no 
ground for making so definite a statement. 

Throughout, the mucous membrane of the urethra presents the orifices 
of tubular glands. Two tubules, much larger than the rest, open upon 
the floor of the urethra near the meatus. Their mouths are not readily 
discernible, except under pathological conditions. They are known as 
Skene's glands. 

Fig. 19. 




Transverse section of the lower portion of the vagina. 
L. Levator ani muscles. R. Rectum. U. Urethra. V. Vagina. 

The Vagina. The vagina is usually described as a musculo-membra- 
nous canal leading from the vulva to the uterus. Lying as it does 
between the bladder and the rectum, its axis varies according to the 
fulness or emptiness of these viscera. Its axis is also dependent upon 
the condition of the pelvic floor. With the pelvic floor intact and with 
the bladder and the rectum empty, the axis of the vagina is nearly par- 
allel with the pelvic brim, except that its lower portion is bulged forward 
by the perineal body. It is evident that its axis will be rendered more 
nearly horizontal by a distended bladder and more nearly vertical by a 



THE FEMALE PELVIC ORGANS. 41 

full rectum. In the virgin, in whom the hymen is still intact, the 
vaginal opening appears as a vertical slit. When, however, the hymen 
has been destroyed the anterior and the posterior walls of the vagina are 
seen to be in contact, and upon cross section its lower end presents an 
outline resembling the capital letter H. The ostium is much the nar- 
rowest part of the canal, even when the latter is distended. A cast of 
the distended vagina has the shape of an inverted truncated cone, and 
that this is the shape of the canal may be demonstrated by exploring it 
with the subject in the genu-pectoral position. The upper expanded 
portion has been designated the fornix or vault. Into it from above 
projects the cervical segment of the uterus. The recesses in front of, 
behind, and at the sides of the cervix uteri are distinguished as the ante- 
rior, the posterior, and the lateral fornices. 

Since the vaginal canal is usually in a collapsed condition, but two 
walls, the anterior and the posterior, demand description. From what 
has been already stated, it will appear evident that both walls are wedge- 
shaped and that the narrow extremities of the wedges are at the ostium 
vaginae. 

Fig. 20. 
^rectal peritoneum 
ecto-uterine pouch 

anterior and pos- 
terior layers of 
broad ligament 

VESICAL 
PERITONEUM 

VESICO-UTERINE 
POUCH 




Vagina 

The neck of the uterus and the upper extremity of the vagina, showing their relation to the peri- 
toneum (vaginal walls in red). 

The capacity of the vagina is increased in every direction by child- 
bearing. In parous women it may have its greatest breadth through the 
middle; but, as a rule, it is broadest at the fornix. This breadth varies 
from 3.5 cm., 1J inch, in nulliparae to double this measurement in mul- 
tiparse. The length of the vagina varies in the different races and in 
different individuals of the same race. In the negress it is longer as 
well as more capacious than in women of the white race. Measurements 
are made along both the anterior and the posterior walls. The average 
length of the anterior vaginal wall in white women is 6 cm., 2 J inches, 
and of the posterior wall 8.5 cm., 3 J inches. The canal is not quite as 
long in virgins, and it undergoes shortening in senile involution. Cases 
of congenital shortening are not infrequently met with in which the canal 
is diminished to half its usual length. The difference in the lengths of 
the anterior and of the posterior vaginal walls may create the erroneous 
impression that the cervix uteri projects through the upper part of the 
anterior wall, and this impression is strengthened by the greater depth 
of the posterior fornix. 



42 



NATOMT. 



The vagina Is a muscular organ Lined by mucous membrane and Bur- 
rounded by dense areolar tissue. This has Led anatomists to describe it 
as having a fibrous, a muscular, and a mucous coat. Its walls vary in 
thickness from 5 mm, to 1 cm., | to ' inch. They arc thinnest at the 
fornix and thickest where the urethra is embedded in the anterior wall. 
This difference in thickness is confined almost entirely to the muscular 
structure. The muscle is of the unstriated variety and has intermingled 

with its fibres a certain amount of elastic tissue. Muscular fibres may 
be made out, taking various courses, circular, Longitudinal, and oblique. 

They interlace, however, in so intricate a manner as to be inseparable 
into distinct strata. They arc continued into the muscular walls of the 
uterus above, and below are lost in the structure of the pelvic floor. It 
is a mistake to state that they are attached to the bony pelvis. 

Fig. 21. 




Longitudinal section of the vagina. 
a. Segment showing posterior wall. 6. Segment showing anterior wall. 

The mucous membrane of the vagina is continuous with that of the 
uterus, and, inferiorly, it covers the hymen and the vestibule. Its 
epithelium is of the pavement variety. This variety of epithelium char- 
acterizes the mucous membrane of the intravaginal surface of the cervix 
uteri also. The vaginal mucous membrane is from 1 mm. to 1.5 mm. 
in thickness, and is closely adherent to the underlying muscular wall. 



THE FEMALE PELVIC ORGANS. 43 

In the lower half of the canal each wall is marked by a longitudinal 
median elevation or furrow — the columna vagince. This is flanked by 
transverse ridges — the rugce or crista vagince. The column upon the 
anterior wail is most marked and seems to originate in the prominent 
mass of tissue surrounding the urethral opening. The crista?, which are 
also best developed upon the anterior wall, are not to be considered as 
folds of the mucous membrane. They are not obliterated when the 
vagina is put upon tension, and are, no doubt, due to an alternate thick- 
ening and thinning of the mucosa. The markings upon the vaginal 
walls are most distinct in the infant and in the virgin. They are obscured 
by childbearing and by catarrhal inflammation. 

A sparing secretion of mucus, acid in reaction, is found upon the 
vaginal walls. Its source is undetermined, since no glands have been 
demonstrated in the mucosa. The reaction of the secretion has been 
supposed to be due to the presence in it of an organism known as the 
bacillus of Doderlein. Recent investigation, however, has rendered this 
theory doubtful. 

Fig. 22. 




7 6 

Sagittal section of the uterus to show the manner in which the peritoneum is attached. 
a. Body of the uterus, a'. Anterior surface, a". Posterior surface, b. Neck. c. Isthmus. 1. Cavity 
of the body. 2. Os internum. 3. Os externum. 4. Posterior fornix. 5. Anterior lip of cervix. 6. 
Anterior vaginal wall. 7. Posterior vaginal wall. 8. Vesico-uterine septum. 9. Wall of the bladder. 
10. Peritoneum. 11. Vesico-uterine pouch. 12. Cul-de-sac of Douglas. 

The muscular walls of the vagina are surrounded by fibro-cellular 
tissue. This serves to support a rich vascular network. The relation 
of the vagina to the tissues forming the pelvic floor has already been 
considered. A short distance above this floor the posterior vaginal wall 
comes in close contact with the rectum. This relation is maintained up 
to the line where the rectum receives its peritoneal covering. The struc- 
tures between the two canals constitute the recto-vaginal septum. Ante- 
riorly the vaginal fornix and the upper part of the canal itself are sepa- 
rated from the urinary bladder by a mass of loose connective tissue. This 
supports the vesico- vaginal plexus of vessels. The relation of the vagina 
to the urethra has been already described. The structures between the 
bladder and the vagina constitute the vesico-vaginal septum. Those 



-11 



ANATOMY, 



between the lumen of the vagina and thai of the urethral canal form the 
urethra^vaginal septum. Laterally the walls of the vagina] fornix arc 
in relation with the bases of the broad Ligaments. 

Prom the foregoing description and that which has already been given 

of the Vesioo-Uterine pouch it will be understood that the anterior fornix 
i- separated by a considerable distance from the peritoneal cavity. Pos- 
teriorly, however, the peritoneum i- reflected from the anterior rectal 
wall forward and upon the vagina. Thence it takes a course upward 
and to the uterus. The posterior vagina] wall below its attachment to 
the uterus is thus covered for a certain distance by peritoneum. This 
distance varies in Length from 15 mm. to 3 cm., f to 1-J inch. Thus 
the posterior fornix i^ in close relation to a peritoneal recess between the 
rectum and the vagina, designated the recto-vaginal pouch or cul-de-sac 
oj Douglas, Laterally the cul-de-sac is bounded by peritoneal folds 
reaching from the upper part of the cervix uteri to the sides of the 
rectum and past the rectum to the second sacral segment. These are 
the folds of Douglas or the utero-sacral ligaments. 

Fig. 23. 



BULB OF_i 
VAGINA WE 




VULVO-VAGINAL 
GLAND 



The vulvo- vaginal gland or gland of Bartholin. (The dotted line indicates the limits of the hulb of 

the vagina.) 



In congenital shortening of the vagina copulation is difficult. How- 
ever, the posterior wall of the vagina may become elongated by repeated 
acts of sexual congress, thus greatly distending the posterior fornix. 

Prolapsus uteri and congenital shortening of the vagina should not be 
mistaken the one for the other, since in simple prolapsus the uterus may 
readily be replaced. 

The Glands of Bartholin. Situated at the sides of the vagina near its 
orifice are two glandular bodies, one upon each side. They are analo- 
gous to Cowper's glands in the male, and are named the glands of Bar- 
tholin or of Duverney. Like its analogue, each gland usually lies between 
the two layers of the triangular ligament. In a very large proportion 



THE FEMALE PELVIC ORGANS. 



45 



of instances, however, it is superficial to both layers of the ligament. In 
either case it is more deeply situated than the vaginal bulb, by the pos- 
terior, rounded, extremity of which it is slightly overlapped. 

The glands of Bartholin vary in size in different individuals, and fre- 
quently upon the two sides in the same person. They attain their greatest 
development in young adults of voluptuous propensities. They become 
flattened by childbearing. Like Cowper's glands, they belong to the 
compound racemose variety. They are of a reddish color and of the 
form and average size of a common white bean. Each gland is supplied 
with a duct about 15 mm., -§ inch, in length and 3 mm., J inch, in 
diameter. This passes obliquely forward or curves round the extremity 
of the bulb to open between the labium minus and the attached border 
of the hymen. The duct at its orifice is contracted and can with diffi- 
culty be discovered. Its location, however, is usually marked by a vas- 
cular area, and may be the better revealed by pressing aside the hymen 
or the caruncula myrtiformis. 

From their location and that of their ducts, the glands of Bartholin 
are also denominated the vulvo-vaginal glands. They are active during 
sexual excitement only, at which time they secrete a yellow viscid fluid, 
which serves a purely mechanical purpose. They do not develop till 
puberty, and they become atrophied in the aged. 

The deep perineal arteries supply the glands of Bartholin. 



Fig. 24. 



Fig. 25. 





The uterus of a virgin seen anteriorly. The uterus of a multi parous woman seen anteriorly. 

1. The body of the uterus covered with peritoneum. 2. The extravaginal portion of the cervix. 

3. The isthmus. 4. The border of the uterus. 5. The intravaginal portion of the cervix. 5'. The 

os externum. 6. The posterior wall of the vagina. 7. The uterine extremity of the Fallopian tube. 

8. The round ligament. 

The Uterus. The uterus is a pyriform body, but it differs in form and 
dimensions in non-parous and in parous women. That of the adult 
virgin when removed from the body weighs between 32 grammes and 42 
grammes, 1 to 1J ounce. Its entire length is about 7.5 cm., 3 inches. 
Near the centre of its length it presents a constriction, the isthmus. This 



46 



ANA TOMT. 



marks the division <>f the organ into body and cervix. The superior 
portion is the body } and the inferior the neok or cervix. Somewhat leas 
than three-fifths <>f the entire Length of the uterus belongs to the body. 
The sagittal diameter at the centre of the body is 2.5 em., 1 inch, and 
that at the centre <»f the cervix very little less. The greatest transverse 
diameter of the body ia about 4.5 cm., 1 | inch, and that of the cervix 

2.5 cm., 1 inch. The diameter.- at the isthmus are somewhat less than 
those of the cervix. The cervical segment IS conical in form, and its 
diameter- are shortest at its free extremity. The posterior surface of the 
body of the uterus is markedly convex, the lateral surfaees slightly so, 
and the anterior surface almost plane. The superior extremity of the 
tuerus is designated the fundus. It is convex both transversely and 
anterc-posteriorly. The lateral angles are known as comua t and here 
are attached the Fallopian tubes, the round ligaments, and the ligaments 
of the ovaries. The cervix uteri is also slightly convex vertically. This 
is least noticeable over its anterior surface, because the sulcus between 
the body and the neck is there least marked. The posterior surface is 
rendered more convex by the bevelling off, or thinning out, of the pos- 
terior lip. The free extremity of the cervix presents a small rounded 
opening — the os tincce or external os. After child-bearing this is con- 
verted into a transverse slit. The circumference of the os tincse is 
divided into an anterior and a posterior lip. The anterior is the thicker 
and apparently the more prominent. 



Fig. 26. 



Fig. 27. 




6 G? 




9 11 

Coronal section of the uterus of a nulliparous Coronal section of the utefus of a multiparous 
■woman. woman. 

1. Fundus. 2. Lateral walls of the body. 3. Cervix. 4. Isthmus. 5. Cavity of the body. 5'. Inter- 
nal wall of the body. 6. Cornu. G'. Opening of the Fallopian tube. 7. Arbor vitce. 8. Os internum. 
9. Os externum. 10, 10\ Lateral fornices. 11. Posterior vaginal wall. 



The uterus is a hollow organ. Its walls, however, are in actual con- 
tact. In sagittal section its cavity is seen to extend from the os tincaa to 
within 2 cm., £ inch, of the free superior surface of the fundus. Its 



THE FEMALE PELVIC ORGANS. 47 

most constricted part is at the junction of the body with the cervix. 
Coronal section shows the cavity of the cervix to be fusiform and that 
of the body triangular. The triangular shape of the outline of the body 
cavity is less marked, however, in parous women. The constriction 
between the cavities of the cervix and of the body is designated the os 
internum. Under normal conditions in the non-gravid uterus it barely 
admits a probe 3 mm., J inch, in diameter. The os internum is situated 
at the inferior angle of the cavity of the body of the uterus. Into the 
lateral angles open the Fallopian tubes. It has already been stated that 
the cervix uteri projects into the upper and anterior part of the vaginal 
vault. The attachment of the vagina to it has led to its division into a 
supravaginal and an infravaginal portion. This attachment of the 
vagina to the cervix is such as to render these portions of about the same 
length anteriorly. Posteriorly, however, the supravaginal portion is 
somewhat the longer. The anterior lip of the cervix is, therefore, 
apparently the longer of the two. 

The cervix of the virgin is conical in shape and is firm to the touch. 
That of the parous woman is longer and more nearly cylindrical, and the 
os tincse is patulous and irregular in outline. 

As a result of childbearing the body of the uterus is somewhat 
enlarged, and the difference between its sagittal and its transverse diam- 
eters is diminished. Its cavity is more capacious and less markedly 
triangular in outline. The whole organ is so changed that the body is 
relatively longer as compared with the cervix. Their lengths now are 
a little more than 2.5 cm., 1 inch, for the cervix, and a little more than 
5 cm., 2 inches, for the body. The weight of the organ is increased by 
about 50 per cent. 

The uterus is essentially a muscular organ. It is lined with mucous 
membrane and partially invested with peritoneum. Its walls are of an 
average thickness of 1 cm., f inch. Though the fibres interlace in 
such a manner as to be inseparable except in the gravid uterus, anatomists 
are almost universally agreed that they are arranged in three distinct 
layers. They are of the unstriated or involuntary variety, and have 
interposed between them connective-tissue cells. The external muscular 
layer or stratum is exceedingly thin, and can be demonstrated upon such 
parts of the uterus only as are covered by the peritoneum, and Avith this 
it is intimately connected. The fibres of this layer pass from the anterior 
and the posterior surfaces and from the fundus upon the Fallopian tubes, 
the round and the ovarian ligaments, and accompany such parts of the 
peritoneum as form the broad and the utero-sacral ligaments. The 
internal muscular layer is so intimately connected with the mucous mem- 
brane as to be, by some, described with it, for, except in the cervix, there 
exists in the uterus no submucosa. The fibres of this layer have a cir- 
cular arrangement. They are augmented at the orifices of the Fallopian 
tubes, at the os externum, and at the os internum. Those at the os 
internum are considered as forming a sphincter muscle. The middle 
muscular layer constitutes much the greatest part of the structure of the 
uterus, and is continuous with the muscular coat of the vagina. It is of 
an average thickness of 6 mm., J inch. The fibres have no definite 
arrangement, but interlace in every direction. They develop in size 
enormously during gestation. This stratum is exceedingly vascular. 



48 



ANATOMY. 



The ooata of the vessels are bo intimately held to the muscular fibres by 
connective tissue that the veins remain patulous <>u cross section. 

The walls of the uterus are thickest over the fundus and at the sides 
<>f the organ. They diminish in thickness at the isthmus and as the 
Pallopiau tubes are approached. 






Fiu. 29. 




External muscular layer of the uterus, seen upon Internal muscular layer of the uterus, seen after 



the anterior surface of the organ. 
1. Tuhe. 2. Origin of round ligament. 3. Origin 
of ovarian ligament. 4. Transverse fibres. 5. Longi- 
tudinal fibres forming the anterior branch of the 
ensiform fascicle. 6. Fascicle in Z-shape. 7. Ex- 
ternal orifice of the cervix. 



removal of the external and middle layers. 

1. Section of external muscular layer. 2. 
Section of middle muscular layer. 3. Fallo- 
pian tubes. 4, 5, 6. Variously disposed fibres. 
7. Os externum. 



The cavity of the uterus is lined throughout with mucous membrane. 
This is continuous with that lining the Fallopian tubes, with the ex- 
ternal mucosa of the infravaginal part of the cervix, and with that 
lining the vagina. It differs in thickness and character in different parts 
of the organ. Its average thickness is 1 mm., ^ inch. Over the 
central part of the cavity of the body it is 2 mm., -^ inch, thick, and 
3 mm., \ inch, in the cervix. In this latter location, as has already 
been intimated, it is more loosely attached to the underlying structure. 
Contrary to the arrangement in most of the hollow viscera, and probably 
by reason of its firmer attachment to the muscular wall, the mucous 
membrane of the body of the uterus is not thrown into folds or rugae, 
except, possibly, at the corn u a. It is of a dark-red color. That of the 
cervix contrasts decidedly with that of the body. The former is lighter 
in color, is firmer to the touch, and is thrown into plica? or folds. It 
should also be noted that the transition from the mucosa of the body to 
that of the cervix is not gradual but abrupt. The line of demarcation 
is at the os internum. To a peculiar arborescent arrangement of the 
folds of mucous membrane in the cervix uteri has been given the name 
arbor vitce uterini (plicce palmatce). On the anterior and on the posterior 



THE FEMALE PELVIC ORGANS. 49 

walls of this cavity is a median longitudinal ridge from which the plicae 
extend upward and outward. As in the vagina, the markings upon the 
anterior wall are the more distinct, and parturition has the effect of par- 
tially obliterating them upon both walls. It has been claimed by Guyon 
that the ridges upon the one wall are so arranged as to fit into the 
depressions upon the other, thus more completely occluding the cervical 
canal. 

Thickly scattered over the surface of the cavity of the body of the 
uterus are the openings of glands. The glands were originally infold- 
ings of the mucous membrane, but have been developed into distinct 
tubules, frequently descending into the underlying muscular structure. 
They may be simple follicles or Have branching extremities. The ducts 
may be straight, or may take a spiral course, but their axes are always 
obliquely inclined to the intra-uterine surface. The walls of the uterine 
glands consist of prismatic or columnar epithelium, supported upon a 
delicate basement membrane. The cells, as well as those of the surface, 
which are also of the same variety, are held together by connective tissue, 
and the connective tissue supports the vessels of the mucous membrane. 
The epithelium of the body of the uterus is provided with cilia. They 
are difficult of demonstration, since they are easily detached and soon 
thereafter lose their characteristic motion. The direction in which they 
propel is downward. 

The mucous membrane of the cervical canal is thicker and firmer than 
that of the body, but is less intimately attached to the subjacent tissue. 
Differences which relate to the circulation will be considered hereafter. 
The presence of papillae, though claimed by Henle, is denied by Klein. 
The glands are of the racemose variety. They are lined by cuboidal, 
non-ciliated epithelium. When their ducts are obstructed the imprisoned 
secretion forms cyst-like bodies upon the surface of the membrane. These 
bodies have been designated the ovula of Naboth. They are pathological 
in character. The surface cells are of the columnar variety to within a 
few lines of the os externum. Here they change, by a dentated border, 
to the variety covering the intravaginal surface of the cervix. The cells 
upon the summits of the plicae are ciliated, while those in the furrows 
are devoid of these processes (Klein). The plicae are absent in the 
lower sixth of the canal. This has led to the erroneous statement that 
the epithelium of the upper part of the cervical canal is ciliated, while 
that of the lower part is not. 

The mucous membrane covering the intravaginal surface of the cervix 
uteri is smooth, closely adherent to the subjacent tissue, and, according 
to Quain, is destitute of glands. It is covered with pavement epithe- 
lium. 

Ligaments of the Uterus. The uterus, during its development, may be 
considered as pushing its fundus upward beneath the peritoneal bag, so 
that this membrane partly covers its anterior and its posterior surfaces. 
This extensive serous membrane is reflected from the bladder upon the 
anterior surface of the uterus at about the level of the isthmus. It 
passes upward over the fundus and downward over the posterior wall to 
the vaginal attachment. It is intimately connected with the external 
muscular stratum of the body of the uterus, so much so as to have led 
anatomists to describe the organ as having a peritoneal coat. ' The ante- 

4 



50 



ANATOMY, 



rior wall <>f the cervix above the vaginal attachment and below the 
isthmus is connected to the bladder by fibro-cellular tissue. 

The peritoneum covering the uterus extends outward from the whole 
Length of each side <>f the body of that organ to the pelvic wall. The 
attachment to the pelvis is 44 from the great sciatic notch downward 



Fig. 30. 




UTERO-OVARIAN 
VESSELS 



DORSAL FOLD OF 
BROAD LIGAMENT 



OS UTERI VAGINA 

The uterus and adnexa viewed from the front. 



along the obturator foramen to the level of the spine of the ischium." 
These two folds of peritoneum, one upon each side, constitute the broad 
ligaments of the uterus. Each ligament consists of two layers of perito- 
neum reinforced by subperitoneal areolar tissue and by muscular fibres 
from the external stratum of the uterus. The broad ligaments together 



Fig. 31. 




Horizontal section through the body of the uterus and the base of the right broad ligament. 
1. Body of the uterus. 1'. Cavity of the uterus. 2. Peritoneum covering the posterior wall of the 
uterus. 3. Peritoneum covering the anterior wall of the uterus. 4. Broad ligament. 5. Uterine artery. 
7. Post-uterine cavity. 8. Pre-uterine cavity. 9. Subperitoneal areolar tissue. 10. Parietal perito- 
neum. 11 Obturator internus muscle. 12. Ischium. 

with the uterus constitute a partition by which the pelvic cavity is divided 
into an anterior and a posterior recess, the deepest parts of which are the 
vesico-uterine pouch and the cul-de-sac of Douglas, respectively. 

The vesico-uterine folds constitute the anterior ligaments of the 



THE FEMALE PELVIC ORGANS. 



51 



uterus or the vesico-uterine ligaments. The recto- vaginal folds form 
the cul-de-sac of Douglas and constitute the posterior ligaments of the 
uterus. Bounding the cul-de-sac on the sides are crescentic folds of 
peritoneum. They extend from the upper part of the cervix uteri, 
or a little higher in parous women, to the rectum and past it to the 
second sacral vertebra. They are known as the utero-sacral ligaments. 
Webster calls attention to the fact that they run backward from the 
uterus in a direction practically parallel with the vagina. Like the broad 

Fig. 32. 




Internal iliac 

arteries 
External iliac 

artery 
Vesico-Vaginal 

artery 



The utero-sacral ligaments or folds of Douglas. 



ligaments, the utero-sacral ligaments are reinforced by fibrous and mus- 
cular elements. 

Development of the Sexual Organs. At the beginning of the seventh 
week the embryonic structures from which the reproductive organs are 
to be developed present the same appearance in both sexes. The intes- 
tinal and genito-urinary canals discharge into a common chamber or 
cloaca. Just within the cloaca, anteriorly, is an elevation of tissue repre- 
senting the future external organs of generation. The canal leading to 
the bladder is comparatively large and is known as the uro-genital sinus. 
In the lumbar region are two glandular structures, one upon each side. 
They are the Wolffian bodies. From their lower extremities the Wolffian 
ducts lead inward and downward to the uro-genital sinus. Upon each 
side another tubular structure may be observed. Above, it lies upon the 
external surface of the Wolffian body. At the lower extremity of the 
Wolffian body it crosses the Wolffian duct, from without inward, and, 
turning downward, runs along its inner side to reach the uro-genital 
sinus. This is the duct of Muller. Medially the lower portion of the 



52 



ANATOMY. 







duotc of Miillci- arc in contact. Subsequently the partition between 
them disappears, and the Bingle tube, thus resulting, becomes the " foun- 
dation iA' the vagina and uterus in tin- female, and the prostatic vesicle 

or uterus masculinus in the male; 
the upper or forepart of the Miil- 
lerian duct disappears in the male ; 
in the female it forms the oviduct " 
(Quain). Arrest of development 
will explain the congenital mal- 
formations of double uterus and 
double vagina. 

The reproductive gland (testicle 
or ovary) is developed from the 
Wolffian body. The Wolffian body 
is held to the posterior abdominal 
wall by a reflection of peritoneum 
from which a fold passes down- 
ward to the groin. After the atro- 
phy of the parent structure its peri- 
toneal investment forms the meso- 
Varium or mesorchium, as the case 
may be, and the descending fold 
(plica gubernatrix) becomes the 
gubernaculum testes in the male 
and the round and ovarian liga- 
ments in the female. The Wolffian 
duct, which in the male develops 
into the vas deferens and the epi- 
didymis, disappears, for the most 
part, in the female. A remnant, 
however, corresponding to the 
globus major, persists as a rudi- 
mentary structure, and is described 
under the name of the parovarium 
or epoophoron. 

As is the case with the testis, so 

the ovary migrates. Its descent 

is arrested, however, by the plica 

gubernatrix becoming attached to the Miillerian duct. This accounts 

for the permanent location of the ovaries and for the attachment of the 

ovarian and the round ligaments to the uterus. 

The Fallopian Tubes. The Fallopian tubes, for the reason that they 
conduct the discharged ova to the uterine cavity, have been denominated 
the oviducts. They are within the folds of the broad ligaments and 
occupy their superior borders, reaching from the cornua of the uterus 
nearly to the lateral pelvic walls. They vary in length from 7.5 cm. to 
12.5 cm., 3 to 5 inches. As a rule, the right tube is somewhat the 
longer of the two. In their development the Fallopian tubes may 
be considered as finally penetrating the broad ligaments, so that they 
open into the peritoneal cavity. The broad ligaments surround them 
much as the peritoneum does the small intestine. Since to the tube is 



Diagram of the primitive urogenital organs in 
the embryo previous to sexual distinction. The 
parts are shown chiefly in profile, but the Miiller- 
ian and Wolffian ducts are seen from the front. 3. 
Ureter. 4. Urinary bladder. 5. Urachus. ot. The 
mass of blastema from which ovary or testicle is 
afterward formed. W. Left Wolffian body. x. Part 
at the apex fiom which the coni vasculosi are 
afterward developed, w, w. Right and left Wolffian 
ducts, m, m. Right and left Miillerian ducts unit- 
ing together and with the Wolffian ducts in gc, the 
genital cord. ug. Sinus urogeiiitalis. i. Lower 
part of the intestine, cl. Common opening of the 
intestine and uro-genital sinus, co. Elevation 
which becomes clitoris or penis. Is. Ridge from 
which the labia majora or scrotum are formed. 



THE FEMALE PELVIC ORGANS. 



53 



applied the technical name "salpinx," the designation mesosalpinx is 
given to that portion of the broad ligament included between the tube 
above and the ovary and the utero-ovarian ligament below. The appear- 
ance of the distal end of each tube is that of a ragged tear through the 
broad ligament above and just external to the ovary. From this point 
to the lateral pelvic wall the superior border of the broad ligament is 
firm and reinforced by fibrous tissue. It presents a sharply concave 
outline. It forms the ligamentum infundibulo-pelvicum or ligamentum 
suspensorium ovarii. 

Fig. 31. 




Fallopian tubes. 

U. Uterus. I. Isthmus. A. Ampulla. F. Fimbriae. F.o. Fimbria ovarica. S. Mesosalpinx. 0. Ovary. 

L. Ligamentum ovarieae. P. Ligamentum infundibulo-pelvicum. E. Parovarium. 

It is quite evident that the position of the broad ligaments, and conse- 
quently that of the ovaries and of the tubes, will vary with that of the 
uterus. The latter organ is not firmly fixed in the pelvic cavity and its 
fundus is especially movable. Concerning the usual position of the 
uterus there has been much controversy. From the intimate connection 
of the cervix to the bladder, anteriorly, and of its proximity to the rec- 
tum, posteriorly, it will be understood that the direction of the long axis 
of the uterus will vary according to the contents of these viscera. "When 
the bladder and the rectum are both empty, the fundus of the uterus will 
drop forward so that the long axis of the uterus will form nearly a right 
angle with that of the vagina, and the uterus will sink wholly beneath 
the plane of the pelvic brim. There may also exist in the organ a cer- 
tain degree of anteflexion. The broad ligaments will now arch about 
the pelvic walls from before backward, and their uterine will be on a 
lower level than their pelvic attachments. When the bladder fills the 
fundus uteri is pushed upward and backward, and may rise above the 
plane of the pelvic brim. The long axis of the uterus becomes then 
more nearly vertical, and the broad ligaments with the uterus assume the 
position described as a transverse pelvic partition. 

When the uterus is in its anteverted position the Fallopian tubes, 
springing from its cornua, curve about tne pelvic brim, superiorly to the 
ovaries, and turn downward and backward around the distal extremi- 
ties of these organs. The fimbriated extremities of the tubes are on a 



64 



ANATOMY. 



level with the h>\\er hordef of the ovaries, posterior to them. The 
curve- in the tubefi are inherent in them, and are not due to their position 

against the pelvic wall-, as may In- proven bv studying them when the 
uterus with it> adnexa Is removed from the body. 

The Fallopian tubes are muscular structures and are lined by an 
extension of the mucous membrane from the uterus. At their distal 
extremities the mucous membrane meet.- the scions surface of the peri- 
toneum. The muscular COal of each tube may he divided into an external 
and an internal layer. The fibres of the external layer are longitudinal 



Fig. B5. 




RTIONS OF 
ROUND LIGA- 
MENT 






The pelvic viscera of woman, seen from above (the left ovary and tube have been drawn up into the 

left iliac fossa). 

and are continuous with the external stratum of the uterus. Those of 
the internal layer encircle the tube and are continuous with the internal 
stratum of the uterus. The circular fibres are greatly increased in number 
where the tube opens into the uterine cornu. 

The oviduct differs so much in form, in diameter, in calibre, and in 
appearance in different parts of its length, as to have led to its division 
into four portions. These are the isthmus, the ampulla, the neck, and 
the fimbriated extremity. The isthmus extends from the uterus for about 
two-sixths of the whole length of the tube. Its diameter is about 3 mm., 



THE FEMALE PELVIC ORGANS. 



55 



J inch. Its calibre at the uterine opening is small, admitting but a 
very fine bristle, but it gradually enlarges toward the ampulla. It has 
a solid or cord-like feel. The ampulla occupies three-sixths of the length 
of the tube, and extends from the isthmus to the neck. It is the most 
tortuous portion, the curve of which has been already described. Its 
diameter increases from the isthmus to the neck, and may reach a maxi- 
mum of 1 cm., or a little more than one-third inch. The diameter of 
its lumen is half that of the tube itself, thus rendering the ampulla less 
firm to the touch than is the isthmus. The distal sixth of the Fallopian 
tube displays a "funnel-shaped expansion surrounded by a fringe of 
peculiar fleshy processes, which recall in a striking manner the tentacles 
of a sea-anemone " (Coe). These ragged fringe-like processes are denomi- 



Fig. 36. 




Left ovary turned up, showing the surface usually in contact with the hroad ligament ; shows also 
the fimbria ovarica and the fimbriated extremity of the Fallopian tube. 
g. The ovary, h. Line of limitation between the ovary and the broad ligament, e. Fimbriated 
extremity of the Fallopian tube. m. Fimbria ovarica. The letter m' lies above the infundibulo- 
pelvic ligament, wbich is cut at the pelvic end. 

nated fimbrice, and they give to this portion of the tube the name fimbri- 
ated extremity. It is the " morsus diaboli" of the ancient anatomists. 
The neck of the Fallopian tube marks the union between the ampulla 
and the fimbriated extremity. Distally the canal of the tube terminates 
in the ostium abdominale. Quain cites authority for the statement that 
this orifice is physiologically closed during life, though dilatable to the 
extent of 4 mm., T ^- inch. The expanded mucous-lined portion of the 
tube distad to the ostium abdominale is designated the infundibulum or 
pavilion. The primary fimbriae are four or five in number, but they 
send secondary offshoots from their edges, presenting a complex appear- 
ance. One of the primary fimbriae, larger and less complex than the 



r' 






I A. I TO i/) . 



others, iu attaohed to the outer extremity of the ovary. It is known as 
thf fimbria ovarioa. 

Flu. 37. 




Fallopian tube laid open. (After Richard., 

a, b. Uterine portion of tube, c, d. Plicceof mucous membrane, e. Tubo-ovarian ligaments and 

fringes. /. Ovary, g. Round ligament. 



Fig. 38. 




Fallopian tube ; cross section through ampulla (Luschka), under low power. 
a. Submucous layer, b. Muscular layer, c Serous coat d. Mucous membrane, e, e. Vessels. 1, 1. 
Small primary folds. 2, 2. Larger longitudinal and accessory folds. 3, 3. Small folds united, forming 
canaliculi. 



THE FEMALE PELVIC ORGANS. 



57 



The mucous lining of the Fallopian tubes is not as closely adherent 
to the muscular structure as is that in the body of the uterus. However, 
it has no distinct submucosa. It is disposed in longitudinal folds, 
which are somewhat more complex in the ampulla than in the isthmus. 
This gives to the lumen of the tube on cross section a stellate appear- 
ance. The furrows are continued upon the fimbriae, so that the fimbria 
ovarica presents a gutter leading from the ovary to the pavilion. The 
epithelium is of the columnar variety and ciliated throughout. The cilia 
possess remarkable activity and produce a current toward the uterus. 
The hytadids or cysts of Morgagni are little bodies sometimes found 
attached by pedicles to the fimbria? or to the broad ligaments adjacent 
thereto. They are remnants of foetal structures. 



Fig. 




Uterus, Fallopian tubes, ovaries, and broad ligaments seen from behind, 
a. Fundus of uterus. 6. Attachment of utero-sacral ligament, c. Cervix, d. Fimbriated extremity 
of Fallopian tube. e. Ampulla of same. /. Isthmus of same. g. Ovary, h. Line of limitation be- 
tween ovary and broad ligament, i. Ovarian ligament, j. Posterior surface of broad ligament, k. 
Fimbria ovarica. 



The Ovaries. The ovaries are the reproductive glands of the female and 
are the analogues of the testicles in the male. Each is an almond-shaped 
body varying in weight and dimensions according to its functional activ- 
ity. In the adult virgin it may be stated to be 4 cm., 1J inch, in length, 
2 cm., j inch, in breadth, and 1 cm., f inch, in thickness. Its weight 
is 8.5 grammes (J ounce). In the parous woman it is diminished in both 
Aveight and volume by about 30 per cent. The ovary may be described 
as having two surfaces, two borders, and two extremities. Sections, 
longitudinal and transverse, show it to be irregularly ovoid. One sur- 
face is the flatter, one border the straighter, and one extremity the nar- 
rower. In its migration from the lumbar region, where it is developed, 
the ovary is arrested and drawn between the folds of the broad ligament. 
It may also be considered as pushed into a pouch (the bursa ovarica) 
formed in the posterior layer of the broad ligament. It is thus com- 
pletely invested by peritoneum except along its straighter border. This 






ANATOMY. 



border, thinner than the other, ig designated the hilum. It la hen' that 
the vessels enter the gland and emerge From it. The ovary, thus invested, 

bangs in the peritoneal cavity from the posterior Surface of the broad 

ligament It- wider extremity is connected to the lateral pelvic wall by 
the ligamentum suspeosorium ovarii; its narrower extremity has attached 
to it the Ligament of the ovary. 

1 1 the fundus of the uterus l>c raised and the broad ligaments stretched 

out, the ovaries hang by their attached borders and their more convex 
BUrtaceS arc in c<>nt;ict with the ligaments. When, however, the uterus 
i> in it< Usual anteverted position the ovaries are in a plane posterior to 
it. They lie upon the lateral pelvic walls, parallel to and 2.5 cm., 1 
inch, or more below the plane of the inlet. Their narrower extremities 
point forward and inward. Moreover, they may turn upward so that 

Fig. 40. 




JO 



•^7 



12 



Sagittal section through the ovary and broad ligament. 
1. Broad ligament. 1'. Anterior surface. 1". Posterior surface. 2. Mesosalpinx. 5. Fallopian tube. 
6. Round ligament. 7. Ovary, 7' Hilum of ovary with vessels entering the same. 8. Graafian 
follicle. 9. Uterine artery. 10. Uterine veins. 11. Cellular tissue at the base of the broad ligament. 
12. Ureter. 

the flattened surfaces come in contact with the broad ligaments and the 
free borders are superior to the hila. The Fallopian tube curves about 
the distal extremity of the corresponding ovary, and the fimbria ovarica 
is applied to the more convex border. The pavilion falls below the level 
of the ovary, but presents toward it. 1 

Each ovary lies in a fossa bounded above by the external iliac artery 



1 The writer has noticed, while experimenting upon the cadaver, that forcible anteversion of the 
uterus causes the ovaries to turn, so that the surfaces, under other conditions in contact with the 
broad ligaments, are lifted and brought more directly into relation with the fimbriated expansions of 
the Fallopian tubes. 



THE FEMALE PELVIC ORGANS. 59 

and below by the ureter. The left may be in contact, internally, with 
the sigmoid flexure of the colon, and the right with a coil of small 
intestine. 

The peritoneal covering of the ovary is so far modified in character as 
to have led some histologists to class it with the mucous rather than with 
the serous membranes. It does not present the glistening appearance of 
peritoneum generally, and miuute examination reveals that it is covered 
with epithelial rather than endothelial cells. The cells are of the col- 
umnar variety. They were supposed by Waldeyer to be the parent cells 
of the ova, whence the name " germinal epithelium/' applied to them. 
After puberty the surface of the ovary is uneven, the unevenness being 
occasioned by the presence of unruptured Graafian follicles and of the 
scars of those which have ruptured and discharged their contents. This 
is especially true of the more convex surface. In old age the entire 
surface of the ovary becomes smooth. 

Pig. 41. 




Section of the ovary. (After Schron.) 
1. Outer covering. 1'. Attached border. 2. Central stroma. 3. Peripheral stroma. 4. Bloodvessels. 
5. Graafian follicles in their earliest stage. 6, 7, 8. More advanced follicles. 9. An almost mature 
follicle. 9'. Follicle from which the ovum has escaped. 10. Corpus luteum. 

If a section be made through the gland its stroma will be found to 
consist of a core of loose connective tissue about which are arranged zones 
of connective tissue of varying density. The peripheral zone is dense, 
though thin. It is of a grayish color, which has obtained for it the name 
tunica albuginea ovarii. It is inseparable from the subjacent tissue, and 
is in no sense a distinct envelope. Underlying the tunica albuginea is the 
zona parenchy matosa or cortical zone. This zone may be subdivided into 
two layers. The superficial layer is the denser of the two. In it are 
embedded undeveloped Graafian follicles to the estimated number (for 
each ovary) of thirty thousand or more. The deeper layer of the cor- 
tical zone is less dense than the superficial. It is very vascular and is 
of a reddish color. It is separately designated the zona vasculosa. 

Bands of fibrous tissue radiate from the hilum throughout the stroma 
of the ovary. Into the zona vasculosa unstriped muscular tissue may 
be traced from the broad ligament of the uterus. 

The Graafian Follicle. The Graafian follicle or ovimc as it develops sinks 
into the zona vasculosa, but owing to its becoming more and more dis- 



till ANATOMY. 

tended with fluid, at maturity it approaches the surface of the ovary. 
Just prior to it- rupture the ovisac presents the following characteristics. 
It is from 1 mm. to 5 mm., Ar to i inch, in diameter. It possesses a thin, 
fibrous envelope continuous, apparently, with the stroma of the ovary. 
This envelope sustains bloodvessels and supports a capillary network of 
the Bame. That pari of the envelope projecting upon the surface of the 
ovary is most vascular, and it is here that the future rupture is destined 
to take place. This point is called the stigma. The investing membrane 
of the follicle is lined with several layers of columnar or cuboidal epithe- 
lial cells. This epithelial Lining has been named the membrana granulosa. 
At some point, usually opposite the stigma, the cells of the membrana 
granulosa are greatly multiplied, constituting the discus proligerus. In 
the cells of the discus profiger us is embedded the ovum. On pricking 
the follicle a drop of clear serum exudes. At maturity, by the accumu- 
lation of this fluid and the consequent distention of the follicle, the 
investing membrane is ruptured at the stigma and the ovum is discharged 
upon the surface of the ovary. 

The Corpus Luteum. After its rupture the Graafian follicle undergoes 
certain changes resulting in what may be considered a scar. This is 
formed by the infolding of the collapsed cell-wall, and it presents a 
Muted appearance. It is of a yellow color, whence its name, the corpus 
luteum. If the discharged ovum undergoes impregnation the develop- 
ment of the corpus luteum is of louger duration, and results in a larger 
cicatrix than when pregnancy does not occur. 

The Parovarium. Lying between the folds of the mesosalpinx is the 
parovarium, epoophoron, or organ of Rosenmuller. It is a foetal relic and 
functionless, but analogous to the epididymis in the male. It consists of 
a number of convoluted tubules. These converge toward the ovary, to 
the hilum of which they are attached near its distal extremity. They 
spread out, fan-shaped, within the mesosalpinx and open into a duct 
which lies parallel with the Fallopian tube and nearer to it than to the 
ovary. The duct may be continued to the uterus, though its lumen 
becomes closed before it reaches that organ. It may present cystic 
enlargements or cyst-like bodies may be suspended from it by elongated 
pedicles. 

The paroophoron consists of several detached tubules lying internally 
to and below the epoophoron (Quain). It corresponds to the organ of 
Giraldes in the male. (Plate II., Fig. 1.) 

The Ligaments of the Ovaries. The ligaments of the ovaries are dense 
fibrous bands about 4 cm., 1 J inch, in length, and receiving muscular 
fibres from the external stratum of the uterus. They connect the ovaries 
and the uterus. They are attached to the narrower extremities of the 
ovaries and to the uterus just below and posterior to the attachments of 
the Fallopian tubes. 

The Round Ligaments of the Uterus. The round ligaments of the uterus 
are fibrous bands or cords containing bloodvessels. They pass from the 
uterus, between the folds of the broad ligaments, to and through the 
inguinal canals. They are attached to the uterus just anterior to the 
attachments of the Fallopian tubes. Between the folds of the broad 
ligaments they each receive an investment of muscular tissue from the 
external stratum of the uterus. 



PLATE 



Fig. 1. 




Meso-salpinx laid open, showing the Parovarium or 
Organ of Rosenmuller. (Savage.) 

T, Fallopian tube; F. fimbriated extremity of same; O, ovary; i, remnant of Wolffian duct; 2, 2, 
remnants of the cseeal tubes of the Wolffian bodies; 3, ovarian ligament. 



Fig. 2. 






$m> : 







Venous Plexuses of the Clitoris, Bulb, Vagina, Bladder 
and Rectum, seen from the side. (Savage.) 

B, bladder partly inflated and with (b) ureter cut; V, vagina; P, section of pubis; C clitoris; 
U, uterus; R, rectum; S, sacrum; 7, veins of the bulb; 2, veins of pars intermedia; j, efferent veins 
to pubic vein; 4, dorsal vein of clitoris; 5, urethral plexus: 6, vaginal plexus; 7 to 12, branches uniting 
to form 13 the internal iliac vein; a, pyriformis muscle; b, great sciatic ligament; c, levator ani mus- 
cle; d, coccygeus muscle; c, suspensory ligament of clitoris; f t bulbo-vaginal gland; g,g,g, roots of 
sacral plexus. 



THE FEMALE PELVIC ORGANS. 61 

In the usual anteverted position of the uterus, the round ligaments 
curve outward, upward, and forward, in front of the ovaries, to reach 
the sides of the pelvis. Here they cross the external iliac arteries. In 
this part of their course they pull forward the anterior layers of the 
broad ligaments, thus appearing to be invested by peritoneum. Leaving 
the broad ligaments they curve forward and inward to the internal 
abdominal rings, through which they enter the inguinal canals. At the 
internal abdominal rings they have the deep epigastric arteries to their 
outer sides. Traversing the inguinal canals they emerge from the exter- 
nal abdominal rings and break up into strands and are lost in the areolar 
tissue of the mons pubis and of the labia majora. 

Though the round ligaments may be well denned throughout their 
entire length, they are, as a rule, difficult of demonstration in the lower 
parts of the inguinal canals, where they frequently consist of fascial 
expansions only. 

In the infant the round ligament is invested throughout with perito- 
neum. This forms a tubular sheath about it, extending well into the 
inguinal canal. It corresponds with the processus vaginalis in the male, 
and is known as the canal of Ntick. As a rule, it is obliterated in the 
adult below the internal ring. However, it not only may persist, but 
may extend beyond the external ring, and into the labium majus. 

The entire length of the round ligament is from 10 cm. to 13 cm., 4 
to 5 inches. Its diameter near the uterus is about 4 mm., T 3 g- inch, 
and for the rest of its length a little less. 

The Connective Tissue of the Pelvis. The spaces between the intrapelvic 
structures which have been described are filled in with connective tissue. 
This serves to unite and support the various organs and to sustain the 
vessels which supply them. It is dense and firm at the vesico-vaginal 
and at the recto-vaginal septum. Between the broad ligaments and 
beneath the utero-sacral bands it is reinforced by muscular tissue, as has 
already been described. In other situations, as between the pubic bones 
and the bladder, about the cervix uteri, between the rectum and the 
sacrum, and at the bases of the broad ligaments, it is loose and areolar in 
character. 

Blood- and Nerve-supply of the Pelvic Floor. With the exception of the 
ovarian arteries all vessels supplying blood to the pelvic structures are 
branches of the internal iliac arteries. The anterior trunk of the internal 
iliac artery on each side lies upon the pyriformis muscle. At the lower 
border of this muscle it divides into the sciatic and internal pudic arte- 
ries. Both of these arteries escape from the pelvis through the greater 
sciatic foramen below the pyriformis. The internal pudic artery, wind- 
ing about the ischiatic spine, returns to the pelvis through the lesser 
sciatic foramen and supplies the genitalia. 

The arteries and nerves supplying the genitalia and the pelvic floor in 
the female correspond with those distributed to analogous structures in 
the male. Their distribution has already been sufficiently discussed. 
Attention should be called, however, to the statement of Ranney, that 
the superficial vessels and nerves perforate the deep layer of the superficial 
fascia in the female, though not in the male. The fact should be men- 
tioned, also, that the superficial artery is larger than its analogue in the 
male, and that it is sometimes called the vulvar artery. In this same 



62 



ANATOMY, 



connection it should be home in mind that the anterior layer of the 
triangular ligament is perforated by the vessels which correspond with 

the dorsal arteries and vein of the penis, and with the arteries to the 
corpora cavernosa and to the bulb in the male. 

The vascular and nervous supply of the bladder and of the rectum is 
practically identical in both Bexes. 

The Vessels and Nerves of the Vagina. The vagina gets its principal 
blood-SUpply from the vaginal arteries. These are analogOU8 to the 
inferior vesical in the male. They may arise directly from the parent 
trunk- or from the uterine arteries. Reaching the sides of the vagina 
they anastomose with the pudic arteries near the ostium, and with the 
uterine arteries oear the cervix uteri. The blood is returned by veins 
which accompany the arteries. First, however, the veins form rich 
plexuses in the vagina] walls both internally and externally to the mus- 
cular coat. (Plate II., Fig. 2.) The veins are devoid of valves and 
communicate freely with the pudendal, vesieal, and hemorrhoidal plexuses, 
and with the plexuses between the folds of the broad ligament. The 
plexus external to the muscular coat consists of large vessels. These 
veins are surrounded by unstriped muscular fibres. Thus is formed a 
p-eudo-erectile tissue. 

Fig. 42. 



TUBAL VESSELS 



ANASTOMOSIS OF 
UTERINE AND 
OVARIAN ARTERIES 
HELICINE BRANCHES ) 



FALLOPIAN 
TUBE 



Ji&S. 




VAGINAL VENOUS PLEXUS 



UTERINE ARTERY 



SUPERIOR VAGINAL 
ARTERIES 



OS UTERI VAGINA CUT OPEN BEHIND 

Bloodvessels of the uterus and its appendages. (Testut.) 



Along the veins of the vagina, and accompanying them, are lymphatic 
canals and spaces. Those of the lower third of the vagina communicate 
with the lymphatics of the vulva, and are drained by the inguinal glands. 
Those of the upper two-thirds join the lymphatics of the cervix and 
empty into a chain of glands which accompany the internal iliac arteries. 

The nerve-supply of the vagina is derived, in the main, from the 
inferior hypogastric plexuses. Branches of the internal pudic nerve are 
distributed to its lower part. 

The Vessels of the Uterus. The uterine artery, upon each side, is given 
off from the anterior trunk of the internal iliac either above the vaginal 






PLATE 



l> -r> 









' 








Lymphatics of the Gravid Uterus and Appendages. (Savage. 



/, 2, superior lumbar glands; j, inferior lumbar glands; 4, sacral glands; 5, external iliac glands; 
6, common iliac glands; 7, ovarian plexus; a, left renal artery; b, left renal vein; c, left ovarian vein; 
d, left ovarian artery; e, aorta; /, common iliac artery; g, ascending vena cava; //, external iliac artery; 
k, common iliac vein; w, », ureters; 0, right common iliac artery, p, iliacus muscle; j, psoas magnus 
muscle; O, ovary reversed to show lymphatics; K, kidney; T, Fallopian tube. 



THE FEMALE PELVIC ORGANS. 63 

or in common with it. It enters the base of the broad ligament and 
descends between the folds to the roof of the vaginal fornix. After 
supplying the cervix it takes an upward turn and reaches the side of the 
uterus at about the level of the os internum. Proceeding upward it 
anastomoses freely at the fundus with the ovarian artery. Throughout 
its course along the body of the uterus it gives off numerous branches 
which, anastomosing with corresponding branches from the opposite side, 
encircle the organ. The parent trunks and their branches, because very 
tortuous in their courses, are spoken of as " the curling arteries of the 
uterus. ' ? One branch, larger than the others, at the level of the isthmus, 
is known as the circular artery. It may sometimes be found below the 
level of the isthmus. 

The fundus of the uterus is supplied by terminal branches of the 
ovarian arteries. 

The arteries of the uterus pierce its muscular walls and terminate in 
capillaries within the mucous membrane. 

The veins are large and abundant in the middle muscular stratum. 
Their coats being intimately united to surrounding tissues render them 
always patulous. Rouget describes a direct communication between 
them and the arteries without capillary intervention. This, if true, 
would constitute the uterus an erectile organ. Under the peritoneal 
covering of the uterus the veins form an intricate plexus which commu- 
nicates freely with that in the vaginal walls and with that between the 
folds of each broad ligament. The plexuses thus formed at the sides of 
the fornix have been named the utero-vaginal plexuses. They are of 
especial interest because traversed by the ureters, which, entering the 
pelvis, cross the iliac vessels from without inward and pass under the 
uterine arteries. The ureters here are about 15 mm., f inch, external 
to the cervix. Having traversed the plexuses above described, they 
curve inward in close contact to the anterior vaginal wall and enter the 
bladder at the lateral angles of the trigone. 

Within the mucous membrane of the uterus are lymph-spaces. About 
the vessels of its muscular walls are perivascular sheaths forming lymph- 
sinuses. Beneath the peritoneal covering is a rich plexus of lymphatic 
vessels. (Plate III.) The lymph from the body of the uterus ulti- 
mately reaches the lumbar glands; that from the cervix enters the iliac 
chain. 

The Vessels of the Fallopian Tubes. The ovarian arteries arise from 
the aorta and descend to the lateral pelvic walls. Each enters the 
broad ligament of its own side, and is guided by the ligamentum infun- 
dibulo-pelvicum to the hilum or attached border of the ovary. Along 
this it pursues a tortuous course, and, leaving it, inclines upward and 
inward to reach the cornu of the uterus between the round ligament 
and the Fallopian tube. It gives branches to the ligament, the tube, 
and the ovary, and supplies the fundus of the uterus, anastomosing with 
the uterine artery. The isthmus and the fimbriated extremity of the 
tube are supplied by branches given off directly from the parent trunk. 
The ampulla is, for the most part, supplied by offshoots from the 
branches which are distributed to the ovary. 

The larger subdivisions of the ovarian arteries are accompanied by 
veins. 



g i .1 \.l TOMT. 

The arrangement of the bloodvessels, as well as of the lymphatics, in 
the Fallopian tubes is similar to thai in the uterus. 

The Vessels of the Ovaries. The branches of the ovarian arteries which 
Bupplv the ovaries are exceedingly tortuous, even to their minute sub- 
divisions. They cover the surface- of the ovaries and enter them at the 
Iiila. Those entering the glands form, in the zonae vasculosse, rich capil- 
lary networks about the ovisacs. The vein- emerging at the hila enter 
plexuses " in which the ovaries and ovarian ligaments seem to be partly 
embedded" (Savage). (Plate IV., Fig. 1.) To these plexuses is some- 
times applied the name of " the bulbs." Upon each side the blood 
from the hull), the Fallopian tube, and the body of the uterus enters an 
extensive venous plexus surrounding the ovarian artery. This is the 
pampiniform (tendril-like) plexus, and is drained by the ovarian vein. 

The ovaries are rich in Lymphatics. The efferent vessels are joined 
by those from the uterus and by those from the tubes. They form 
plexuses within the folds of the broad ligaments, and the lymph from 
them enters the lumbar glands. 

The Nerves of the Uterus, Tubes, and Ovaries. The uterus is supplied by 
branches from the inferior hypogastric plexuses of nerves, though branches 
from the ovarian plexus as well reach its fundus. The inferior hypo- 
gastric plexuses supply the Fallopian tubes also. The ovaries receive 
their nerve-supply from the ovarian plexus. The method of termina- 
tion of the nerves in the ovaries is undetermined. They have been 
traced into the hilum, where they form a network about the vessels. 
Some investigators claim to have traced them to the Graafian follicles. 

The Inferior Hypogastric Plexuses. The inferior hypogastric are also 
called the pelvic plexuses. (Plate IV., Fig. 2.) They are situated at 
the sides of the rectum, the bladder, and the vagina. In their distribu- 
tion their branches accompany the internal iliac arteries. The plexuses 
are formed by filaments from the hypogastric plexus of the sympathetic 
joined by nerves from the sacral ganglia and branches of the second, 
third, and fourth sacral nerves. The nerves which supply the vagina 
accompany the vaginal arteries. They are derived almost entirely from 
such parts of the inferior hypogastric plexuses as come from the cerebro- 
spinal axis. The nerves which supply the vaginal fornix, the cervix 
uteri, the body of the uterus, and the Fallopian tubes accompany the 
uterine arteries, and upon them may be demonstrated ganglionic enlarge- 
ments. 

The Ovarian Plexus. The ovarian plexus is derived from the renal and 
aortic plexuses of the sympathetic system. It surrounds the ovarian 
arteries, and in its distribution accompanies its branches. 



THE MAMMARY GLANDS. 

The mammary glands exist in males and in females alike. There is 
little or no difference between them in the sexes during infancy and child- 
hood. As the age of puberty approaches the gland of the female under- 
goes a rapid and characteristic development. That of the male remains 
rudimentary throughout life, although rare exceptions to this rule exist. 
The location of the mamma? upon the anterior chest-wall has obtained 




Bulb of the Ovary and its Venous Communications. (Savage. 

O, ovary; T, Fallopian tube; U, uterus, 
i, uterine veiu and plexus; 2, subovarian venus plexus; 3, commencement of ovarian vein. 



Fig. 2. 




Nerves of the Pelvic Organs. (Savage.) 

R, rectum; U, uterus; B, bladder; P, pubis; .S, section of the ilium; D, trail sversus perinei muscle. 
1, hypogastric plexus; 2, rectal plexus; 3, a lumbar ganglion; 4, 4, ovarian plexus; 5, branch from 
third and fourth sacral nerves; 6, 7, right inferior hypogastric plexus; 8, uterine filaments; 9, vesical 
plexus; 10, great sciatic nerve; 11, levator ani branch from fourth sacral nerve; 12, pudic nerve; 13, dis- 
tribution of pudic nerve to clitoris. 



THE MAMMARY GLANDS. 



65 



for them the common name of the breasts. Embryology teaches that the 
glandular structure is a modification of the sebaceous glands. Super- 
numerary mammae may, therefore, occur as accidents of development. 
When existing they are usually small and located upon the chest or in 
the axillae. They may, however, attain considerable size and may be 
formed upon other parts of the body. 

The female breasts differ in size and in appearance in different indi- 
viduals. These differences depend upon age, race, condition in life, 
nutrition, and the activity or quiescence of the gland. In the same 
person, the left breast is generally somewhat larger than the right. 

Fig. 43. 





Breast of virgin, showing pink areola and position of gland 



In a well-developed, non-parous white woman the breasts appear as 
hemispherical or conoidal masses, one upon each side. In the negress 
they are pendulous. They are firm to the touch. Each is about 5 cm., 
2 inches, in thickness. The circumference of its base is slightly ellip- 

5 



66 ANATOMY. 

tical, the major axis being directed upward and outward toward the 
axilla. Internally it overlaps the bonier of the sternum. Externally 

it is hounded by the mid-axillary line. Vertically it is bounded above 
by the seeond or third rib, and below by the sixth or seventh rib. Its 

weight averages L75 grammes, or between live and six ounces. 

Fig. 44. 








Nipple and areola. (Cooper.) 

At the most prominent part of the breast is the nipple or mammilla. 
It usually appears as a conical wart-like excrescence. Sometimes it is 
flattened and ill-defined, or its site may be marked by a depression. 
Surrounding the nipple is a zone of modified integument. It is desig- 
nated the areola. The areola is about 2.5 cm., 1 inch, in width. The 
color of the nipple and of the areola varies with the complexion of the 
individual. In blondes they are a rosy pink ; in brunettes a delicate 
brown. Though the nipple is slightly below the centre of the breast, 
it points upward and outward when the body is in the upright position. 
This is due to the sagging of the base of the gland. The nipple is 
then about opposite the fourth intercostal space. 

The skin of the nipple and of the areola differs from that of the rest 
of the breast and from skin generally. That of the nipple is tough 
and leathery. It is beset with numerous sensitive papillae, is wrinkled 
from the presence within it of unstriped muscular tissue, is supplied 
with large sebaceous glands, is destitute of hairs or of sweat-glands, and 
is perforated near its centre by the openings of the milk-ducts. The skin 
of the areola is delicate in texture. It is abundantly supplied with 
sudoriparous glands. Hair follicles are present. The sebaceous glands 
are markedly developed. They open upon little elevations which give 
to the areola a tuberculated appearance. Xear the base of the nipple 
the ducts of a variable number of accessory milk-glands open upon the 
areola. 

As the first pregnancy advances the breasts increase in size. The 
nipples also enlarge and become cylindrical in shape. The areolae widen 
and undergo deeper pigmentation. The sebaceous glands of the areola? 
become more active. The elevations marking their ducts become more 



THE MAMMARY GLANDS. 



67 



prominent. They are now known as the glands of Montgomery. During 
lactation the breast may weigh, according to Testut, as much as 500 
grammes, or over fifteen ounces. 

After lactation the breasts decrease in size, but do not regain their 
former appearance. They lose firmness and become soft and pendu- 
lous. The nipples remain prominent and the areolae wide. In blondes 
the areolae may assume their original color, but in brunettes they remain 
deeply pigmented. 

Fig. 45. 





Breast of woman who has been pregnant, showing pigmented areola and position of gland. 



The mammary gland is made up of from twelve to twenty lobes, each 
of which may be considered a distinct gland. The lobes are pyramidal 
in form, their apices being represented by ducts which discharge at the 
nipple. They are encapsulated by a fascia which sends processes between 
them and between the lobules of which they are composed. The cap- 
sule of the mammary gland is concave toward the chest-wall. It is 
attached to the fascia of the underlying muscles by connective-tissue 
bands. These may enclose lymph-spaces, the so-called submammary 
bursas. Occasionally little masses of glandular tissue perforating the 
capsule lie embedded in the pectoral muscle. 

Internally the breasts lie upon the pectoralis major muscles; externally 
and below they overlap the interdigitations of the serratus magnus with 



68 



ANATOMY, 



the externa] oblique muscles; externally and above they arc separated 
{"rmii tin- Berratue magnus muscles by the axillary fascia). 

The convex surface of the capsule enclosing the Lobes is uneven. It 
Bends processes to the overlying skin known as the ligaments of Cooper. 

Except beneath the nipple and the areola the superficial fascia of the 
breast contains fat. Fat is also found in the fascia between the lobes. 
I rpon the quantity of fat depend- in a great measure the Bizeof the breasts. 
Beside the lobes constituting the gland proper, minute glandular bodies 
may be found near the base of the nipple. They are the so-called acces- 
sory glands. They are from five to twelve in number. Their duets may 
open independently upon the surface of the areola or may open into the 
principal duet- traversing the nipple. 



SECOND 
RIB 
PECTORALIS 

MINOR 
NTERCOSTALES 
SHEATH OF PEC- 
TORALIS MAJOR 




LUNG 

ADIPOSE TISSUE 
HORIZONTAL PLANE 
OF NIPPLE 



SIXTH RIB 



Sagittal section of mamma and chest-wall. 

The glandular tissue of the breast may be distinguished from the sur- 
rounding fat by its pinkish color and its firmer consistence. Each lobe is 
a compound racemose gland, and consists of a number of lobules. The 
lobules are surrounded and supported by fibrous connective tissue derived 
from the interlobular septa. Each lobule consists of ultimate acini or 
alveoli arranged about a central canal. The canals unite to form the 



THE MAMMARY GLANDS. 69 

interlobular ducts. The interlobular ducts unite to form the principal 
duct of the lobe. This is the tubulus lactiferi, or galadophorous duct. 

Before lactation and during subsequent periods of functional inactivity 
the acini are small and undeveloped. They consist of a membrane (mem- 
brana propria) enclosing a mass of granular polyhedral cells. During 
pregnancy they enlarge, and the central cells soften. At the commence- 
ment of lactation the central cells are discharged as colostrum corpuscles. 
The peripheral cells are of the short columnar variety and line the 
membrana propria. The walls of the ducts are of areolar tissue, in 
which elastic fibres are disposed in both a circular and a longitudinal 
manner. Quain states that there is no muscular tissue in the walls of 
the ducts. This is certainly not true of the larger ducts. Near the 
nipple the tubuli lactiferi show the presence of unstriped muscular fibres 
interlacing and taking courses both circular and longitudinal. The 
latter may be traced for a certain distance into the lobes, and some in- 
vestigators even claim to have discovered stray fibres in the interlobular 
ducts. The epithelium of the ducts varies in different parts of the gland. 
That of the lobular and interlobular ducts resembles the epithelium of 
the acini. That of the main duct is distinctly cylindrical, except very 
near its termination, where it changes to the squamous variety. 

Fig. 47. 




Anatomical arrangement of milk-ducts. (Cooper.) 

When formed by the union of the interlobular ducts the tubuli lacti- 
feri converge toward the nipple. Beneath the areola they form sac-like 
dilatations or ampullce. During lactation the ampullae are about 12 mm., 
-J- inch, in length, and 6 mm., i inch, in diameter. They act as reser- 
voirs for the milk secretion during the intervals of suckling. Beyond 
the ampullae the ducts contract in size and lie side by side in the nipple. 
The central ones are somewhat the larger. All open independently of 
one another and by contracted mouths at depressions upon the apex of 
the nipple. 

The arteries of the breast are numerous but small. They do not 
accompany the ducts, but enter at the base of the gland. The inner and 
greater portion of the breast is supplied by the internal mammary artery, 
the anterior or perforating branches of which pierce the intercostal spaces 
to reach it. The anterior intercostal branches of the internal mammary 
artery and the aortic intercostals with which they anastomose, in like 
manner supply the inner portion of the mammary gland. The outer 
portion gets its blood-supply from the axillary artery through its long 
thoracic and acromio-thoracic branches. To the long thoracic branch of 
the axillary artery is frequently applied the name external mammary. 



70 



J.v.i TOMY. 



An accessory external mammary branch may also !»»• given off from the 
axillary artery and go to the supply of the breast A rich capillary net- 
work i- found upon the outer nail- of the acini. 
The blood is returned from the breast through superficial and deep 

win-. The deep veins accompany the arteries for the most part. The 

Superficial vein- form an anastomosing circle at the base of the nipple 
uhts '•- iiusus of Mailer;. They Bpread over the surface of the breast 

and end in the superior thoracic vein. The superficial veins are espe- 
cially noticeable during lactation. 



Fig. 48. 




Showing arterial supply of breast. (Testut.) 
A. Mammary gland. B. Pectoralis major muscle. D. External oblique muscle. E, F. Digitations 
of serratus magnus muscle. G. Deltoid muscle. 1. Internal mammary artery. 1', 1". Perforating 
branches of the same. 2. Superior thoracic artery. 2'. Branches of the same. 3. Long thoracic 
artery. 3'. Branches of the same. 4. Superficial vessels of the breast. 5. Perforating branches from 
the aortic intercostal arteries. 6, 7. Axillary artery. 



The nipple is exceedingly vascular, and the vessels are surrounded by 
bundles of unstriped muscular tissue. The contraction of the muscular 
fibres upon stimulation compresses the vessels and causes the so-called 
erection of the nipple. It is not to be understood, however, that the 
nipple contains any true erectile tissue. 



THE MAMMARY GLANDS. 



71 



The lymphatics of the breast are abundant. They form plexuses in 
the connective tissue about the acini and between the lobules. They 
are found accompanying the smaller vessels and in the sheaths of the 
larger ones. All freely communicate. There are, beside, sac-like dila- 
tations in the skin and fascia, from which cutaneous and subcutaneous 
lymphatics originate. The lymphatics from the inner portion of the 
breast accompany the perforating arteries and empty into the medias- 
tinal glands. Those from the outer portion unite and form three or four 
large trunks. They proceed to the axillary glands. A few canals from 
the vicinity of the nipple empty into a gland situated beneath the outer 
border of the clavicle. 

The nerve-supply to the breast is principally from the intercostal 
nerves through the lateral cutaneous and the anterior terminal branches. 
The descending branches of the superficial cervical plexus also contribute 
cutaneous filaments. The glandular twigs which accompany the ducts 
to the acini have been traced by Eckhard from the fourth, fifth, and 
sixth intercostal nerves. On account of the free communication between 
the spinal nerves and the gangliated cord, sympathetic nerves are con- 
ducted to the mammary gland. " In the nipple many nerves end in 
tactile corpuscles in the papillse, and some of those in or near the areola 
enter Pacinian corpuscles" (Quain). 



Fig. 49. 




Lymphatics of breast and axilla. (Cooper.) 



In the periods between lactation the acini collapse, but do not return 
to their former undeveloped condition, and the connective tissue contains 
a greater amount of fat than before the gland became functionally active. 
At the close of the child-bearing period the whole structure undergoes 
atrophy, so that in old age the glandular tissue has practically disap- 
peared. 



PART II. 

PHYSIOLOGY OF PREGNANCY. 



CHAPTER II. 

MENSTRUATION.— OVULATION— DEVELOPMENT OF THE OVUM. 
MENSTRUATION. 

This is the periodical discharge of blood from the uterus which takes 
place during the whole of genital life — the years included between 
puberty and the climacteric — the period of pregnancy excepted. In 
occasional instances menstruation may also occur during the early months 
of gestation, but after the fifth month, when the decidua reflexa has 
joined the vera and disappeared, the normal source of the discharge is 
completely shut off, and bleeding from the uterus subsequent to this 
time must be due either to a diseased condition of the cervix or to some 
other pathological condition of the uterine tissues. 

Menstruation occurs on the average once in twenty-eight days, but it 
is subject to wide variations in point of time, some women menstruating 
normally at shorter, others at longer, intervals. The duration of the flow 
is usually from three to five days, but it may continue for two or three 
days longer and still remain within normal limits. Every healthy 
woman must be considered a law unto herself in the matter of frequency 
and duration. The source of the flow is the uterine fundus and body. 

At first the discharge is made up of mucus, epithelia, and some blood ; 
later it consists of nearly pure blood, and finally of a diminishing amount 
of blood, serum, epithelia, granular debris, and some fat. The reaction 
of the discharge is acid from the presence of phosphoric and lactic acids ; 
it is non-coagulable from the admixture of mucus; and it has a peculiar 
penetrating odor due to contained fatty acids. From four to eight 
ounces are lost at each period. 

The function is associated with more or less general and local disturb- 
ance, especially of a secondary or reflex character. 

The primary cause of the flow is to be sought in the ovary, viz., 
in ovulation. The processes affecting the uterus during the menstrual 
act may be considered as taking place in four stages, as follows : (1) A 
period of construction in which the uterine mucosa becomes tumefied, 
the stroma is infiltrated with serum which often contains blood, the 
vessels are dilated, and the number of epithelial cells lining the glands 
is augmented, while the glands themselves become dilated and filled with 
mucus. This condition is probably similar to that which follows impreg- 
nation, the swollen mucous membrane in this instance being called the 
decidua menstrualis. (2) A period of destruction in which the integrity 

(73) 



71 



PHTSIOLOG V OF PREGNANCY. 



of the uterine Lining is destroyed, the exposed capillary vessels rupture 
and pour oul their blood, which carries with it the products of disin- 
tegration. (3) A period of regeneration in which the swelling and 

hyperemia subside, and the uterine lining is rapidly renewed by the 
proliferation <■(' the stroma cells and the upgrowth of the epithelial cells 
of the glands. This takes place between the sixth and the eighteenth 
day from the beginning of the period (Westphal). These changes are 
followed by (4) a period of quiescence or repose, in which no active 
changes take place in the uterine lining. 

OVULATION. 

This consists in the periodical discharge of the fully ripened ovum 
from the Graafian follicle, and, like menstruation, is probably con- 
fined to the period of genital life. The development of the egg-cell 
from the germinal epithelium is described elsewhere. The young ovum 
is at first surrounded by a single layer of small cells, but by division of 
these a wall several cell-layers deep is finally formed. Between the 
external and the innermost layer a fissure is then developed, the latter 
becoming filled with fluid — the liquor folliculi. The innermost layer of 
cells is thus forced away from the wall, and as the fluid increases a 



Fig. 50. 
PS KE PS 

! ! 




g So Ei Mp 

Development of the Graafian follicle (Wiedersheim). 
KE. Germinal epithelium, from which Pfliiger's tubes, PS, in ovarian stroma are developed. So. 
Ovarian stroma, g, g. Small vessels. U, U. Primitive ova. S. Space between membrana granulosa 
and ovum. Lf. Liquor folliculi. D. Discus proligerus. Ei. Ripe ovum, with germ-vessicle and ger- 
minal spot (K). Mp. Membrana pellucida. Tf. Muscular sheath of follicle. Mg. Membrana granulosa. 

vesicle is formed, the cells adhering around the ovum as the discus pro- 
ligeru8j which remains attached to the follicle wall at one point only, 
the farthest from the surface. The wall of the Graafian follicle is com- 
posed of the following layers from within outward : (a) membrana gran- 
ulosa ; (6) the membrana propria, a very thin basement membrane; (c) 



DEVELOPMENT OF THE OVUM. 75 

the tunica propria, which carries the smaller bloodvessels and is com- 
posed of more or less fibrous tissue; and (d) the tunica fibrosa, contain- 
ing much fibrous tissue, aud through which run the larger bloodvessels. 

At one place in the follicle wall (the stigma) no bloodvessels are devel- 
oped, and it is at this point that rupture occurs and permits the escape 
of the ovum surrounded by the discus proligerus and the liquor folliculi. 
Just before rupture of the follicle certain preparatory changes take place, 
the maturation of the follicle, which lead up to the event. The blood- 
vessels become engorged, the internal layer of the wall becomes thick- 
ened and is thrown into folds, and the liquor folliculi is largely augmented. 
At this time the Graafian follicle projects from the surface of the ovary 
as a currant-like cyst. 

After the escape of the egg-cell the follicle undergoes certain changes, 
the nature of which is dependent upon the fertilization or otherwise of the 
ovum, the product in either instance being the corpus luteum. When 
fecundation of the ovum does not take place the corpus luteum of menstru- 
ation, corpus luteum spurium, is formed. The bursting of the follicle re- 
lieves the pressure on the surrounding bloodvessels, which rupture into 
the cavity, the discharged blood forming a firm clot, which, however, does 
not become attached to the follicle wall. The hypertrophy of the follicle 
wall, already begun, continues, the wall being thrown into irregular folds 
which encroach more and more upon the central clot. Contraction of the 
clot follows, and capillary loops surrounded by newly formed cells from 
the follicle wall penetrate its substance. As these changes progress gran- 
ules of lutein are formed in the external layer of the clot which give rise 
to its yellow color. The further changes in the corpus luteum are of a 
retrograde character, the clot and newly formed products gradually disap- 
pearing, until after eight or nine weeks only a small cicatrix on the surface 
of the ovary remains. It is stated by Dalton that seven or eight months 
may elapse before the total obliteration of the follicle has taken place. 

In the event of impregnation, the corpus luteum of pregnancy — corpus 
luteum verum — results. Under this condition, instead of diminishing in 
size, the corpus luteum continues to enlarge up to the fourth month, the 
walls becoming thicker and their convolutions more numerous. From the 
fourth to the seventh month a stationary period occurs, but from this 
time on the corpus luteum begins to decline, so that at term it is much 
smaller than at the fourth month. After labor the retrograde changes 
are rapid, and by the eighth or ninth week post partum nearly all traces 
of the corpus have disappeared. 

Although menstruation and ovulation should not be considered as 
necessarily coincident processes, it is altogether probable that the condi- 
tions which influence the one have also an effect upon the other, and 
that, as a rule, the two functions occur simultaneously, and are to a 
greater or less extent interdependent. 

DEVELOPMENT OF THE OVUM. 

Maturation ; Fertilization. The fully developed human ovum is a 
single cell, more or less spherical in form, about y^- inch in diameter, 
and composed of a yolk, a nucleus, a nucleolus, and two enveloping 
membranes. (Fig. 51.) 



7»; PHYSIOLOQ F OF PREGNANCY. 

The outermost membrane, Zona radiata or Zona pellucida, is rather 
thick and tough, and presents a Btriated appearance, owing to the pres- 
ence "f numerous minute pore-canals. It is derived from the secretions 
of the ovarian tissues. 

The second or Vitellim nu mbram , lying in close contact with the yolk 
from which it Is developed, is a very thin and delicate covering, the 
existence of which has been denied by some writers. 

Pig. 51. 



CELLS OF 
-CORONA. 




A RADIATA. 



UCLEUS. 



GERMINAL-/ • H>> / Wfo% i<"£W\ GERMINAL 

VESICLE. / ;i : ^)lMMSir SP^- 

FOOD YOLK. 



Rabbit's ovum (after Waldeyer). 

Between the zona and the second membrane there is a narrow cleft, 
the Perivitelline space, which permits free motion of the ovum within its 
external covering. 

The Yolk or Vitellus is a clear, somewhat granular substance, consisting 
of yolk-grains (food-yolk or deutoplasm), some fat granules, and proto- 
plasm. The latter is usually increased in amount at one point in the 
ovum, and this part is designated the animal pole, while the correspond- 
ing opposite point, where the protoplasm is less, is known as the vege- 
tative pole. 

The Nucleus of the ovum, also called germinal vesicle or vesicle of 
Purkinje from its discoverer, occupies an eccentric position in the egg- 
cell, and is surrounded by a nuclear membrane. A reticulum or net- 
work of achromatic threads radiates from the nucleolus through the 
interior of the nucleus ; the meshes of this structure are filled with a clear 
fluid, the nuclear sap. 

The Nucleolus, Germinal spot or spot of Wagner, is also placed eccen- 
trically in the nucleus, and is largely composed of chromatin — a sub- 
stance having a marked affinity for staining reagents. 

The female cell or ovum, thus briefly described, although fully devel- 
oped, is still in an unripe condition, unprepared for the reception of 
the male fecundating element, and must undergo a series of changes, 
which principally affect the nucleus and nucleolus, before fertilization 
can be accomplished. These changes are known as the maturation of 
the ovum, and take place just before or just after the ovum has escaped 
from the Graafian follicle, occurring without reference to the future fate 
of the egg-cell. 

The first step in the process of maturation is the contraction of the 



DEVELOPMENT OF THE OVUM. 



77 



entire yolk. The nucleus then travels toward the animal pole of the 
egg, loses its sap, which becomes mingled with the surrounding proto- 
plasm, and the nuclear membrane shrinks and finally disappears. Achro- 
matic threads then appear in the nucleus in the form of a spindle-shaped 
body, which lies parallel with the surface of the egg, each thread bearing 
a chromatic granule near its middle, which gives rise to the appearance 
of a dark band near the centre of the nuclear spindle. 

A clear space at each end of the spindle then develops threads which 
run to the surrounding yolk substance, the sun-like appearance thus 
produced being termed the Amphiaster. 

The nuclear spindle now assumes an upright position, the chromatin 
granules divide, each half travelling toward its corresponding end of the 
spindle, while the spindle itself surrounded by protoplasm advances to 
the surface of the egg and pushes outward one-half of its entire sub- 
stance into the perivitelline space. This extruded portion then becomes 
constricted off from the rest of the spindle, and forms the first polar 
globule. (Fig. 52.) 

Fig. 52. 
> SZS ^9 




-fp 



Formation of polar globules in arteria gracialis (after O. Hertwig). 
>. Nuclear spindle. Pg. First polar globule. Spg. Second polar globule, fp. Female pronucleus. 



The remnant of the spindle in the egg then a second time undergoes 
the changes just described, and forms in the same manner a second polar 
globule. Three-fourths of the original spindle is thus cast off. The 
remnant of the spindle retires into the egg and becomes the female 
pronucleus. 

No entirely satisfactory explanation for the formation of the polar 
globules has been advanced; but it is supposed to be effected either to 
lessen the size of the cell nucleus in order to make room for the male 
element, or to prevent self-fertilization, parthenogenesis. 

Fertilization. The ovum, now fully ripe and in condition for fertiliza- 
tion, migrates through the Fallopian tube toward the uterus. The point 
at which the two elements, male and female, meet, is not definitely 
known, but it is supposed to be the outer portion of the tube in the 
majority of instances. 

Recent observations go to show that impregnation may take place any- 
where from the Graafian follicle in the ovary to the cavity of the uterus. 



7S 



PHYSIOLOG V OF PREGNANCY, 



Of the whole Dumber of ova which arc discharged from the ovary it 
Lg quite probable thai many do aol cuter the tube at all, but fall into 

the peritoneal cavity and perish. In very rare instanco the ovum from 
one ovary Is knOWIl to have passed entirely around the litems, and 
entering the tube of the opposite Bide to have there become fertilized. 

When the spermatozoa and ovum meet, the former penetrate the zona 
radiata, and the first spermatozoon which approaches the vitelline radi- 
allv ig met l>v a Blight protrusion of the; protoplasm of the egg, which it 
penetrates and, passing inward, enters the yolk. Here the spermatozoon 
loses it- tail, and the head, composed largely of chromatin, becomes the 
nude pronuch us. 

Bui one spermatozoon is necessary for fertilizing the ovum, and as 
soon as this has penetrated the yolk a repellent action seems to beset up 
by the latter, whereby other spermatozoa are prevented from passing 
inward. 

After a short resting stage the male and female pronuclei approach 
(Mich other, and, their walls coming in contact, fuse, finally disappear, and 
a single nucleus, somewhat smaller than the original one of the ovum, 
remains as the segmentation nucleus. 

The ovum now enters upon a new stage of development, in which the 
entire egg-cell is broken up into a great number of smaller cells, each 
of which possesses a nucleus. This total division of the ovum is known 
as holoblastic segmentation, the individual cells of which are called blas- 
tomeres. (Fig. 53.) This change first affects the segmentation nucleus 

Fig. 53. 



ZONA 

PELLUCIDA 



POLAR 
GLOBULES 




Diagram showing first stages of segmentation in a mammalian ovum (Allen Thompson, after 

E. van Beneden). 



which divides by the indirect method (karyokinesis), and forms two 
nuclei. A groove then appears in the axis of the ovum, marked by the 
polar globules, which by continuous deepeniug completely divides the 
ovum into two cells. A second groove at right angle to the first cleaves 
the two cells into four, a third groove at right angle to the other two 
gives rise to eight cells, and, the process continuing, the ovum is finally 
converted into a mass, which, from its resemblance to the fruit, is called 



DEVELOPMENT OF THE OVUM. 



79 



the Morula or mulberry-body. The process of cell division, although 
described as equal, is not so in fact, for the external cells divide more 
rapidly than the internal, so that there can be differentiated two distinct 
layers, a superficial layer in which the cells are small, and an internal 



Fig. 54. 




Optical section of an oosperm of a rabbit, at two stages closely following upon segmentation (from 
Balfour, after Ed. v. Beneden) : ep, ectoderm ; hy, primary entoderm ; bp, the opening in the ecto- 
dermic layer at one point, named blastopore by E. van Beneden ; this is not a true blastopore. The 
shading of the ectoderm and entoderm is diagrammatic. 

layer in which they are much larger. At about the time that the 
morula stage is reached a cavity — the segmentation cavity — makes its 
appearance between the two layers. This is filled with a clear albumi- 
nous fluid which increases rapidly in amount, so that the ovum soon 



Fig. 55. 




Babbitt's ovum between seventy and ninety hours after impregnation (after van Beneden). 

becomes distended into a vesicle, the blastodermic vesicle or blastula. 
(Fig. 54.) On section the blastula is seen to consist of a cavity sur- 
rounded by a single layer of small cells, within which at one point a lens- 
shaped collection of larger cells is attached. (Fig. 55.) With the growth 



80 



PHYSIOLOGY OF PREi . SANCY. 



of the blastula the cells of the external layer — Raubertfe covering layer — 
become greatly thinned and flattened, and ultimately either disappear or 
are united to a third layer formed by a proliferation of the cells from the 
inner cluster, (Fig. 56.) Thus there is at one stage of development an 







Later stages of segmentation in a mammalian ovum (Thomson, after E. van Beneden). 

external thin layer of cells, covering layer, under which there is a second 
layer of small cells which extends around the entire inner surface of the 
blastula, and a third layer comprising the inner cluster of large cells. 

The covering layer, as stated, disappears, the second layer becomes the 
ectoderm, and the third layer the entoderm. 

Fig. 57. 




Transection of eighteen-hour chick embryo, showing beginning of medullary groove and the three 

layers (Manton collection). 
a. Ectoderm, b. Mesoderm, c. Entoderm. 



From the cells of the two layers thus formed, a third layer — the meso- 
derm — is developed, and grows outward from the median axial line. 
(Fig. 57.) Unlike the other two layers the mesoderm does not at 
first extend entirely around the ovum, but is limited in growth by 
the germinal or embryonic area (Fig. 58), that portion of the egg in 
which the future embryo will be developed. The mesoderm grows in 
all directions, but as it extends cephalad it sends out two projections, 



DEVELOPMENT OF THE OVUM. 



81 



which, leaving a space (the proamnion) just in front of the future head, 
again unite and spread outward. (Fig. 59.) 



Fig. 58. 




Embryonic area of rabbit (after Kolliker). 

At a later period two distinct varieties of cells arise from ^ the meso- 
derm— mesothelium, which develops the characteristics of epithelium— 
and from this mesenchyme or embryonic connective tissue. 



Fig. 59. 



ap-~. 



pr— 




-pr 



Diagrams of embryonic area of chick (after Duval). 
ao. Area opaca. ap. Area pellucida, the proamnion in third figure, pr. Primitive streak. 

mes. Mesoderm. 

From these three primary layers all the parts and tissues of the body 
are developed. 

From the Ectoderm : The skin and its glandular structures, the mam- 

6 



PHYSIOLOGY OF PREGNANCY. 

mary -lands, hair, nails, epithelium of the cornea, the lens of the eye, 

the cerebrospinal system, the nerves and ganglia, the optic vesicles and 

nerve, cavity of the month, teeth, hypophysis, aims, chorion, amnion, 
placenta. 

From tli' Mesoderm : The muscles, hones, connective tissue, perito- 
neum, pleura', pericardium, urogenital apparatus (kidneys, testes, uterus, 
Fallopian tubes, and ovaries), spleen, bloodvessels, blood, Lymphatics, 
fat-cells, marrow. 

Prom the Entoderm : The oesophagus, stomach, intestines, epithelium 
of digestive tract, thyroid and thymus glands, tonsils, lungs, liver, pan- 
creas, bladder. 



Optic vesicles. 

Mid-brain. 

j Hind-brain. 

_j — • Primitive segments. 
-\ — Medullary groove. 

— _ Sinus rhomboidalis. 



Chick embryo. Second day. (Manton collection.) 

At an early stage a linear streak — the primitive streak — (Fig. 58) 
makes its appearance just behind the centre of the embryonic area, and 
runs backward to near the margin of the shield. In front of the primi- 
tive streak the ectoderm thickens into a band of cells several rows deep 
on either side of the median axial line. These thickenings are the medul- 
lary plates. By the upgrowth of the edges of the plates a groove is 
formed — the medullary groove — which by the arching inward and unit- 
ing of the lateral folds is converted into a tube, the medullary or neural 
canal. The formation of the canal begins in the future cervical region 
of the embryo, and progresses most rapidly cephalad ; the posterior por- 
tion, the end of which appears to embrace the beginning of the primi- 
tive streak, remains open for some time, and is known as the sinus 
rhomboidalis. (Fig. 60.) 



DEVELOPMENT OF THE OVUM. 



83 



The neural canal is the proton of the cerebro-spinal system, one-half 
of its entire extent entering into the formation of the brain. Imme- 
diately below the developing neural canal a rod of cells is formed in the 
entoderm, and extends from the future hypophysis to the anterior end of 
the primitive streak. This is the notochord, or chorda dorsalis (Fig. 61, 
6 Cd.)j a temporary structure which represents the primitive axial skeleton 
of vertebrates. Developed from the entoderm, the chorda is at first a part 
of that layer, but the latter soon growing under it becomes separated and 
assumes a position directly beneath the neural canal, with which, how- 
ever, it does not unite. 

On either side of the neural groove the mesoderm becomes thickened 
into two longitudinal bands — the muscle plates. That portion of the 
plate nearest the groove is thickest and is known as the segmental zone, 
while the external portion which thins toward the blastodermic wall is 
the parietal zone. 




Fig. 63. 




Fig. 64. 




Qnmjjjrj, 



The segmental zone undergoes transverse cleavage which gives rise to 
a series of cubical bodies — the myotomes (see Figs. 61 to 66). These 
appear first in the neck region of the embryo, and gradually extend 
caudad. The myotomes give rise to most of the voluntary muscles of 



84 



PHYSIOLOGY OF PREGNANCY. 



the trunk, and later to those of the extremities, and arc Indirectly con- 
nected with the formation of the future vertebra. 



: 




Figs. 61-66— Development of the neural canal (after Waldeyer). 
Ec. Ectoderm. Ent. Entoderm. Mes. Mesoderm, a, b. Prota of primitive segments (protovertebrae). 
Md. Medullary groove. Mp. Medullary plate. A. Aorta. Cd. Notochord. X Wolffian ridge. Wd. 
Wolffian duct. Vc. Cardiual vein. So. Somatopleure. Sp. Splanchnopleure. C. Ccelom. 

Externally to the parietal zone of the muscle plates, the mesoderm splits 
into two layers, an upper or external leaf going with the ectoderm to 
form the somatopleure or primitive body wall, and a lower or internal 
leaf which, with the entoderm, forms the splanchnopleure or primitive 
intestinal wall (see Figs. 61 to 66). The space between these two leaves 
is the coelom or body cavity (pleuro-peritoneal cavity). 

Folding of of the Embryo. Up to this time the embryo appears to lie 
flat on the blastodermic wall, but now changes arise which tend to carry 
it more and more from its surface position and to force it downward into 
the cavity of the blastula. A groove first appears just in front of the 
cephalic end of the embryo (Plate V., Fig. 11), the head fold, and later 
one behind, the tail fold, and on either side the lateral folds are formed. 
As the result of the deepening of these folds, the embryo becomes partly 
constricted off from the rest of the blastodermic vesicle. As the folds 
deepen, spaces are shut off at the anterior and at the posterior ends 
of the embryo, immediately below the notochord. These cavities are 
the beginning of the primitive alimentary canal; that in front being 
the fore-gut, and that behind the hind-gut. The middle portion of this 
canal, as it soon comes to be, is still in connection with the yolk-sac or 
umbilical vesicle, by the wide omphalomesenteric or vitelline duct. 
(Plate V., Figs. 3 to 10.) 

The Foetal Appendages and the Uterine Membranes. As the result of 
the folding off of the embryo, all of the extra-embryonic portion of the 
egg, which constitutes the yolk-sac, becomes partially constricted off as 
a pear-shaped body, which is connected by its smaller end to the primi- 
tive intestinal canal. At a later period the neck of the vesicle becomes 



PLATE V. 




al f 



DEVELOPMENT OF THE OVUM. 85 

stretched out into a long thin pedicle, and pedicle and sac are finally 
incorporated in the abdominal stalk during the formation of the umbilical 
cord. The yolk probably supplies for a time partial nourishment to the 
embryo and its appendages. During its passage through the Fallopian 
tube the ovum also derives more or less nourishment from the secretions 
of the parts by which it is surrounded. As development of the embryo 
goes on a larger source of supply is demanded, to which end changes 
take place, bringing the embryo into direct relation with the maternal 
circulation, by which the necessary nourishment for growth and develop- 
ment is obtained. 

At a very early period all of the extra-embryonic somatopleure be- 
comes covered with a growth of delicate villi, which give it a shaggy 
appearance. This is the primitive chorion ; the whole ovum at this time 
being sometimes called the chorionic vesicle. (Fig. 67.) 

Fig. 67. 



5s 




Human ovum of second week, showing chorionic tufts, A. Enlarged four times. (Manton collection.) 

At first the villi are composed only of ectodermal cells, but later the 
mesoderm extends into each hollow villus. The whole chorion very 
early develops bloodvessels, but most of these soon become obliterated. 

Coincident with the folding off of the embryo the external walls of 
the folds grow upward and, arching over the back of the embryo, unite 
in the mid-dorsal line. The anterior fold, cephalic cap, probably grows 
more rapidly than the lateral folds, but little is actually known regarding 
this phenomenon from observations on human embryos. The embryo in 
this way becomes inclosed in a thin membranous sac — the amnion. As 
will be seen by reference to Plate V., the amniotic folds are composed 
of two layers, an upper, external leaf — the false amnion — made up of 
ectoderm externally and lined with mesoderm, and a lower or internal 
leaf — the true amnion, which has a layer of mesoderm above and ecto- 
derm below, and hugs the back of the embryo. 



Description of Plate V. 

Folding off of embryo and formation of amnion and allantois in fowl's egg (after O. Hertwig). 

a. External germinal layer, mw. Medullary groove. N. Neural canal, af. Amnion fold. vaf. 
Anterior, haf. Posterior, saf. Lateral amniotic folds. A. Amnion, ah. Amniotic cavity. S. Serous 
covering, hn. Umbilicus, sf. Lateral folds, kf 1 , kf 2 . Head fold. afb. External, ifb. Internal layers 
of amnion, ur. Border of embryonic area. dr. Intestinal groove, dg. Vitelline duct. al. Allantois. 
ds. Vitellus. dn. Intestinal portion of umbilicus, mk. Middle germinal layer. mk l . Parietal leaf 
of mesoderm, ink 2 . Visceral leaf of mesoderm, st. Sinus terminalis. dm. Dorsal, vm. Ventral 
mesenterium. Ih. Somatic cavity. IK 1 . Embryonal portion. lh 2 . Extra-embryonal portion of somatic 
cavity. Figs. 1, 2, 6, 8, 9, and 10 transections. Figs. 3, 4, 5, 7, and 11 longi-sections of embryo. Figs. 
1, 2, 3, 4, and 5 chick embryo. Fig. 6 fish embryo. Figs. 7 and 11 selachian embryo. 



86 



PHYSIOLOGY OF PBEQNANOT, 



The cavity between the two layers is called the amniotic earth/, and is 

later filled with fluid. At first the amniotic membrane lies in contact 
with the hack of the embryo, bat soon a clear fluid, the amniotic fluid 
or liquor amnu, is Becreted within the sac, and this increasing in amount 

rapidly distends the amnion until some time during the third month this 
membrane COmefl in contact with the chorion, with which it forms a loose 
attachment. The Liquor amnii is a clear, serous fluid, having a specific 
gravity of 1007 to L028, an alkaline reaction, and a composition includ- 
ing fixed solids, epithelial scales, lanugo, and other matters derived from 

Fig. fis. 



J^r . ^A0»'~X* J „ 




Embryo with open membranes. Fifteen to eighteen days. (Coste ) 
1. Allantois (abdominal stalk). 2. Parietal mesoblast. 3. Vitelline membrane, yolk. 4. Amnion. 

5. Heart. 

the embryo or foetus, besides water. It amounts to about sixteen or 
eighteen ounces at term, and is derived by transudation from the mater- 
nal structures. The function of the liquor amnii is manifold: it main- 
tains an equable distention of the uterus, protects the child from external 
violence, and permits of its free movements in utero; it prevents injuri- 
ous pressure on the umbilical cord, and, during labor, softens and lubri- 
cates, as well as assists in the dilatation of, the parturient canal. It is, 
moreover, a source of water-supply to the foetus, bathing its surfaces, 
and being swallowed in considerable quantities. 

By the formation of the amnion the embryo becomes entirely separated 



DEVELOPMENT OF THE OVUM. 



87 



from the chorion except at its caudal end, which remains fixed as the 
abdominal stalk. (Fig. 68.) At an early period a bud-like diverticulum 
— the allantois (see Plate V., 3 and 4) — develops from the posterior 
ventral end of the hind-gut, and growing outward soon reaches the 
chorion, with which it becomes joined and assists in the formation of 
the placenta. 

The allantois lies beneath the abdominal stalk, and early in its devel- 
opment becomes attached to the lower surface of that part, the two 
together forming the proton of the umbilical cord. 




Semi-diagrammatic outline of an antero-posterior section of the gravid uterus and ovum of five weeks 

(modified from Allen Thomson). 

a. Anterior uterine wall. b. Posterior uterine wall. c. Decidua vera. d. Decidua reflexa. e. De- 

cidua serotina. ch. Chorion with its villi. 

The impulse started by the fecundation of the ovum inaugurates cer- 
tain changes in the uterus preparatory to the reception of the fertilized 
egg, changes which in their earlier stages are probably analogous to those 
taking place at the menstrual period. The whole uterus enlarges, becomes 
more vascular, and its mucosa appears more vascular, spongy, and swol- 
len. At the os internum and the openings of the Fallopian tubes the 
mucous membrane remains thin, so that, as the result of hypertrophy, 
the parts surrounding these apertures are thrown into folds. The entire 
thickened lining of the womb is designated as the decidua vera. (Fig. 69.) 

As soon as the chorionic vesicle enters the uterus, it is usually arrested 
in one of the folds nearest the tube opening, and at once attaches itself 



88 PHY8I0L0GY OF PBEGNANCY. 

to the uterine wall. The folds by which it is Burrounded then now for- 
ward, arch over the vesicle, and, their edges uniting, it becomes entirely 
enclosed as within a aac, These encompassing folds — thedeoidua reflexa 
— as the amnion expands are pushed more and more toward the decidua 

vera, with which they ultimately come in contact and unite during the 

fourth month. 

The reflexa i- a temporary structure and disappears by degeneration 
and absorption by the fifth month of pregnancy. 

That pari of the uterine mucosa upon whicb the chorionic vesicle first 
linds lodgement is the decidua aerotina ; it plays an important role in the 
future vascular arrangements between the mother and child. 

The Placenta and Umbilical Cord. When the chorionic vesicle reaches 
the uterus the tips of the villi penetrate the mucosa, and the embryo is 
at first nourished by osmosis from the maternal structures. The villi of 
the serotinal region, however, rapidly outgrow those of the rest of the 
vesicle, so that this part has been called the chorion frondosum, in dis- 
tinction from the remainder, the chorion Iceve, which atrophies and disap- 
pears some time prior to the fourth month, the former increasing and 
entering into the formation of the placenta. At term the placenta or 
afterbirth (Figs. 70 and 71) is a roundish, oval, or kidney-shaped 
spongy mass, reddish-gray to deep purplish-red in color, with a diameter 
of six to eight inches, and weighs about a pound. It is usually thickest 
at the centre, and gradually thins off toward the edges, which are con- 
tinuous with the amnion and decidua. The placenta consists of three 
essential layers : (1) A maternal zone of decidua, (2) a foetal zone of 
amnion and chorion, and (3) a middle zone in which both the maternal 
and the foetal elements are intimately associated. 

The inner or foetal surface of the placenta, to which the cord is attached 
excentrically, is smooth and glistening in appearance, and is coshered by 
the amnion, beneath which the two umbilical arteries and one umbilical 
vein ramify in all directions. The veins are the larger and lie deeper 
and internal to the arteries. The external portion of the placenta pre- 
sents a rough and irregular surface which in the recent stafe is covered 
with blood and clots. It is broken into asymmetrical patches or 
squares, the cotyledons, between which the decidua serotina dips down 
forming partitions or septa. 

As already pointed out, the caudal end of the embryo is prolonged to 
the wall of the chorionic vesicle as the abdominal stalk. The latter, 
therefore, consists of the same structures as the remainder of the embryo, 
and possesses a rudimentary groove, a somatopleure, and a splanchno- 
pleure. At first the amnion springs from the sides of the stalk. 

By the down growth of the two somatopleural leaves and the uniting 
of their edges on the ventral side of the stalk, a tube is formed, the cavity 
of which is continuous with the cavity of the coelom, and within which 
the allantoic diverticulum and the pedicle of the yolk-sac are imprisoned. 
As a result of the closing in of the tube, which is hereafter known as the 
umbilical cord, the amnion becomes separated from the abdominal stalk, 
the separation beginning at the embryonic end and extending to the 
chorionic attachment. Thus, as has been demonstrated by Minot, the 
umbilical cord is at) no time covered by the amnion. The cavity of the 
cord becomes obliterated at an early stage, and the allantois and yolk- 



h 
< 

a 




3 

03 

<D 
< CO 



c 

CO 



0- 



a 
= c 

3 .2 
c w 

a 

CO 



DEVELOPMENT OF THE OVUM. 



89 



stalk atrophy and disappear, although it is claimed by some observers 
(Kolliker, Minot) that the allantois can be distinguished at birth. 

At term the cord has been compared to a " twisted rope of tissues/ ' 
extending from the placenta to the child. The cord is of a glistening 
grayish-white color, of varying thickness, and is usually about 22 inches 
long, but may be either much longer or shorter. 

In structure the cord consists of a covering of epithelium continuous 
with that of the amnion, which surrounds a jelly-like matrix called 
Wharton's jelly. This consists of mucin, branched corpuscles, and em- 
bryonic connective-tissue cells. Within this substance the two arteries 
and one vein run in a spiral course, usually from left to right; it is to 
the fact that the growth in length of the vessels exceeds that of the rest 
of the cord that the twisted appearance of the latter is probably due. 



Fig. 70. 




The internal or foetal surface of the placenta. 



Utero-placental Circulation. The most comprehensive explanation of 
this difficult problem has been advanced by Bumm, whose conclusions 
may be summarized as follows : The decidua gives rise to numerous 
processes between which the chorionic villi penetrate. (Plates VI. 
and VII.) The arteries of the processes run in an irregular manner 
with many spiral turns, and as they approach the surface of a process 
become tuft-like, and losing their coats open freely into the intervillous 
spaces. The veins open at the bases of the processes and along the 
decidual margins of the intervillous spaces. The chorionic villi, there- 
fore, hang more or less freely in a blood- filled sinus. Each decidual 
process, cotyledon, has its individual circulatory region, the blood pour- 
ing out from the sides of the process and re-entering the maternal circuit 
through the veins at its bottom. 



90 



PHYSIOLOQ V OF PREGNANCY. 



The greater the distance from the decidual process, the slower becomes 
the blood-current, until a point is reached where absolute stasis occurs 
with resulting fibrin deposit The circular sinus at the edge of the 
placenta receives the blood from the lowest processes, but, as it appears 
often interrupted, it can bave 1 >ut Limited importance in carrying off the 

blood. The chorionic villi very rarely if ever penetrate into the mouths 

of tli«- arteries, bul they do enter the veins and often for a consider- 
able distance. (Plate VII.) 

Fig. 71. 




The external or uterine surface of the placenta. 



The Embryonic and Foetal Circulation. At a very early period of devel- 
opment the embryonic area presents, on surface view, a netted appearance, 
due to cord-like thickenings in the splanchnopleural mesoderm. Scat- 
tered among these cords are reddish-yellow patches, blood-islands or 
islands of Pander, the cells of which develop haemoglobin, which gives 
rise to their color. This reticulated region is called the area vasculosa, 
and it is bounded by a large vessel, the sinus terminalis. (Fig. 79.) 
By a process of liquid vacuolation the mesodermal cords become hol- 
lowed out, and acquiring a lumen give rise to the primitive bloodvessels. 

An extension of the vascular network takes place by the uniting and 
anastomosing of bud-like offshoots from the primitive vessels, which 
extend toward and finally penetrate the embryo, where they unite with 
the embryonic vessels. 

Coincident with the formation of the extra-embryonic circulation, the 



DEVELOPMENT OF THE OVUM. 



91 



embryonic heart is developed and begins to pulsate before connection 
with the vessels has been established. 

As the result of splitting of the mesoderm and the folding off of the 
embryo, the splanchnopleural leaves are forced downward, and, approach- 
ing each other, unite in the ventral median line. Before this is accom- 
plished a small cavity makes its appearance in the splanchnic mesoderm 



Fig. 72. 




Fig. 73, 




h h 
Schematic representation of the development of the heart (after O. Hertwig). 
h. Heart, spl. Splanchnopleure. 

of either side in the cephalic region of the embryo. By the down-fold- 
ing of the splanchnopleure these cavities come to lie ventrad to the future 
throat, and are gradually brought together, their walls fusing. (Figs. 
72 to 74.) These cavities are the proton of the primitive heart, which 
is at the start a double tube. The middle Avail of the heart-tube soon 
disappears, a single cavity resulting. The mesodermal cells of the heart 
cavity undergo changes which give rise to the endothelial lining of the 
completed organ. At first the heart is attached to the surrounding 
tissues by a ventral and a dorsal mesocardium, but the former and a 
portion of the latter disappear, leaving the heart projecting freely into 



92 



PJIYsioLOtiY OF PREQA INCY. 



the ooelomic cavity. The upper end of the heart-tube then dilates into 
w hut will be the future aortic bulb. 

In the further development of the heart the Lengthening of the tube 
in a confined -pace causes it to assume an S-shaped bend to the right, 




Endothelial heart of a human embryo (after His). 
A.b. Bulbus aortce. F.r. Fretum Halleri. V. 
Ventricle. V.h. Auricle. V.o.m. Omphalo-me- 
Benteric vein. V.u. Umbilical vein. V.c. Vena 
cava. C.a. Auricular canal. 



■V.c.d. 



Endothelial heart (after His). 
A.b. Bulbusaortce. F.r. Fretum Halleri. V. Ven- 
tricle. P. Wall of pericardium. V.u. Umbilical 
vein. V.o.m. Omphalo-mesenteric vein. V.c.d. 
Cardinal vein. V.j. Jugular vein. V.h. Auricle. 
C.a. Auricular canal. 



that portion to the right and in front representing the future auricles, 
that to the left and behind the ventricles. (Figs. 75 and 76.) 

The auricular portions on either side expand and become somewhat 




Endothelial heart of a human embryo (after His). 
Sv. Sinus venosus. Ho. Auricle. Ca. Auricular canal. VI. Ventricle. 



constricted off from the ventricle, the opening between the two being the 
auricular canal. (Fig. 77.) A partition — the septum superius — then 
develops from above, and growiug downward to the auricular canal con- 



DEVELOPMENT OF THE OVUM. 



93 



verts the single auricle into right and left cavities. At a later stage the 
septum is perforated above, giving rise to the foramen ovale, an opening 
between the auricles which persists until some time after birth. The 
separation of the ventricles is first indicated by a groove on the exterior 
of the heart, a septum inferius developing from a corresponding point in 
the interior, and extending nearly upward to the auricular canal, a small 
foramen remaining open. (Fig. 78.) At the same time a division of 
the aortic bulb takes place, the septum extending downward to and 
fusing with the septum inferius. This division of the aortic bulb gives 
rise to two vascular channels, that to the left and in front becoming the 
pulmonary artery, while that to the right and behind is the permanent 
aorta, which has for its opening the interventricular foramen. 



Fig. 78. 




Inner surface of heart (after His). 
V.C.S. Superior vena cava. S.S. Septum superius. V.E. Eustachian valve. 
A.E. Auricular canal. S.I. Septum inferius. 



S. Area interposita. 



Coincident with the development of the heart and the extra-embryonic 
circulation, bloodvessels have been forming in various parts of the em- 
bryo, and with the uniting of these vascular channels a primitive circu- 
lation is soon established. 

Primitive Embryonic Circulation. (Fig. 79.) The anterior end of the 
heart prolonged as the truncus arteriosus soon divides in the region of 
the fifth branchial arch into two primitive aorta?, which run forward and 
bend around on either side to the dorsum of the embryo, ^vhere they con- 
tinue longitudinally to the caudal end. From the aortse branches are 
given off, the chief of which, the omphalo- mesenteric arteries, carry most 
of the blood to the capillaries of the vascular area. The return current 
from the sinus terminalis is carried by the anterior and posterior vitelline 
veins, which unite near the middle of the embryo with the omphalomesen- 
teric veins to form a large trunk, the sinus venosus, which enters the 
posterior end of the heart. 

Secondary Embryonic Circulation. Arteries. With the development 
of the allantois and its union with the chorion, further changes in the 



94 



PHYSIOLOGY OF PREGNANCY. 



circulation take plaoe. The posterior portions of the two primitive 
aorteB Ease to form a single permanent dorsal aorta, from which branches, 
the vitelline arteries, are given off to the yolk-sac, and two terminal ves- 
sels — the allantoic arteries — which carry the blood from the placenta to 
the embryo. 

Fig. 79. 

Dc. 



sr. 




Card. 



Oni. V. 
Diagram of the circulation of a chick at the end of the third day, as seen from the under or ventral 

side (after Minot). 
Ht. Heart. Arc. Aortic arches. Dc. Ductus Cuvieri. Jug. Jugular vein. Ao. Aorta. Card. Car- 
dinal vein. Om.A. Omphalic artery. Om. V. Omphalo-m esaraic vein. ST. Sinus terminalis. SV. 
Sinus venosus. 

The truncus arteriosus also gives off five paired branches — the aortic 
arches — which run right and left around the visceral arches to the primi- 
tive aorta of the corresponding side. (Fig. 80, A.) 

These arches develop from in front backward, and disappear in the 
same order, so that the five pairs are never in a state of perfect develop- 
ment at the same time. By the fourth week changes begin to take place 
in the arches which are indicative of the permanent adult vascular 
arrangement. The internal portions of the first arch on either side 
become the external carotid arteries; the third arch and the dorsal por- 
tions of the first and second arches give rise to the internal carotid ; the 
ventral portions represent the common carotids. 

The left fourth arch enlarges, becoming the permanent aortic arch, 
while the right fourth arch becomes distinctly smaller, loses its connec- 
tion with the aorta, and dividing gives rise to the vertebral artery and its 
branch, the subclavian, of the right side. (Fig. 80, B.) The left fifth 
arch gives off the left pulmonary artery, which at first communicates 
with the dorsal aorta through the ductus arteriosus (ductus Botalli). The 
right fifth arch disappears above the origin of the pulmonary artery of 
that side. 



DEVELOPMENT OF THE OVUM. 



95 



The iliac arteries arise from the umbilical arteries — the proximal por- 
tions of the allantoic arteries — during the development of the posterior 
extremities. The remainder of the allantoic vessels become the hypo- 
gastrie arteries. 

Fig. 80. 



Exc 




Exc. 



I ii ill IV v 



A. Diagram of pharynx of an amniote vertebrate. B. Diagram of gill arches as preserved in 

mammals (after Minot). 
The shaded portions are those which remain, the unshaded those which disappear. Inc. Internal 
carotid. Ao. Aorta. Ph. Pharynx. Oe. (Esophagus. Hi. Heart. Exc. External carotid. M. Mouth 
invagination. 1, 2, 3, 4, 5. Gill pouches (clefts). I, II, III, IV, V. Aortic arches, da. Ductus arteri- 
osus. P. Pulmonary artery. 

Veins. The blood is returned to the heart by four sets of vessels : 
the jugular, the cardinal, the vitelline, and the umbilical veins. The 
two jugulars receive the blood from the head, the two cardinals from the 
trunk, and both unite to form the ducts of Cuvier, which enter the heart 



Fig. 81. 




ilcd 
He 




vTfc 



ilcs 

Hi 




Diagramatic figures illustrating the development of the venous system (after O. HEETwrG). 
dc. Ductus Cuvieri. je,ji. External and internal jugular veins. S. Subclavian vein. vh. Hepatic 
vein. V. Umbilical vein, ci, ci 2 . Vena cava inferior, ca, ca 1 , ca 2 , ca 3 . Cardinal vein. ilcd. Right and 
left common iliac veins, ad, as. Right and left brachio-cephalic veins, cs. Vena cava superior, cc. 
Coronary vein. az. Azygos vein, hz, hz 2 . Hemiazygos vein. He. External iliac. Hi. Internal iliac, 
r. Renal vein. 



96 PHYSIOLOGY OF PREGNANCY. 

by fche nnus venoms. At a later period the right Cuvier'a duct becomes 
the superior vena cava : the left aucl disappears. 

The oardinala are in intimate relation with the Wolffian bodies, and 
on the resorption of the latter a middle part of the left cardinal disap- 
pears, it- anterior portion becoming the hemiazygos vein. The right car- 
dinal gives rise to the oaygos vetn f and the posterior portions of both 
cardinals t<> the internal idee veins. (Fig. 8 1 . ) 

The 1»1 1 ifl returned to the yolk-sac by the two vitelline veins, which 

enter the embryo at the umbilicus, run cephalad along the splanchno- 

plenral mesoderm beside the primitive gut, and empty into the sinus 

l'i imsi/s. 

In the hepatic region the vitellines are united by three transverse 
branches, and, after forming two vascular rings around the duodenal 
portion of the gut, break up into smaller vessels which enter the liver. 
These vessels are afferent, carrying the blood to the liver, where a capil- 
lary network is established; they later become (Fig. 82) branches of the 

Fig. 82. 




Diagram of the liver veins (aft* r His). 
Ts. Stomach. Va'. Right allantoic vein. VI. Ductus venosus or vena Arantii. Vh. Efferent hepatic 
vessel. VI. Afferent hepatic vessel. Vo. Portal vein. Vi. Vitelline vein. W. Liver. Wd. Bile duct. 
Va. Left allantoic vein. Ti. Intestine. Va. The white vessels represent those which are aborted. 

portal vein. From the capillary network the blood is collected by effer- 
ent vessels which carry it to the heart; these vessels become the hepatic 
veins. At a later period the portal vein is developed, from the two 
vascular rings, the right side of the upper ring and the left side of the 
lower ring disappearing, a single vessel remaining, which makes a spiral 
turn around the intestine. 

In the allantoic stalk the two umbilical veins fuse, forming a single 
vessel, which again separates within the embryo and, running in the 
somatopleure to the liver, empties into the duct of Cuvier. After a time 
the right umbilical vein dwindles and breaks up into several branches, 
some of which join the efferent hepatic veins as they leave the liver, 
while the remainder disappear. The left umbilical vein enlarges and 
joins the portal vein just as this vessel enters the liver. 

"When the vitelline and umbilical veins lose their direct connection 
with the heart — on account of the intercalation of the hepatic circu- 



PLATE VII 




Diagramatie Representation of a Human Embryo estimated as 

about Four Weeks old, showing Heart, Blood Vessels, 

Brain and Abdominal Viscera. (Modified from His.) 



Hs, hemispheres; Ast, optic stalk; Zh, 'tween brain; Mh, mid-brain; Js, isthmus of hind-brain ; 
Cb, cerebellum; Cc, ciliary ganglion; Rl, olfactory lobe; Rg, nasal pit; GG, Gasserian ganglion; 
Ga, ganglion of auditory nerve ; Gh, auditory vesicle ; Gl, ganglion of glossopharyngeal nerve ; Gvg, 
ganglion of vagus nerve; Hp, hypoglossal nerve; Ci, ganglion of first cervical nerve; Ok, superior 
maxilla; UK, inferior maxilla; Lg, tongue; KK, larnyx ; Sa, septum atrium; Sv, septum ventricu- 
lorum ; C, internal carotid; Lg, lung; L, liver; St, septum transversum ; Vp, vena porta; ; On, 
Wolffian bodies; Ms, mesentery ; Dr, intestine; CI, cloaca; Bl, kidney proton; V, ventricle; Au, 
auricle. 

The dorsal aorta and internal carotid arteries are indicated in light red ; 
the cardinal and jugular veins are in blue. 



DEVELOPMENT OF THE OVUM. 97 

lation — the liver soon becomes unable to accommodate the increasing 
quantity of blood which passes through it, so that a communicating vessel 
is formed which connects the portal vein, just before it enters the liver, 
with the right hepatic vein just before it terminates in the sinus venosus. 
This is the ductus venosus, and through it the greater quantity of blood 
is carried directly to the heart without having to traverse the liver 
capillaries. 

The vena cava inferior is developed as a small vessel from the ductus 
venosus, and runs through the liver caudad between the kidneys to ter- 
minate in the iliac veins. 

The pulmonary vein at first empties into the left auricle by a single 
opening, but about the fourth month two or three mouths have developed 
and remain permanent. 

The Blood. The primitive red cells are derived from the endothelial 
lining of the vessels and from the blood-islands. According to Minor, 
they are at first spherical, the nucleus is large, and they are surrounded 
by a layer of protoplasm. They multiply by indirect division. Before 
the formation of the lymph-glands little is known regarding the origin 
of the white blood-cells. 

The Embryonic Circulation. In the primitive or vitelline circulation 
the blood is collected from the vascular area by the vitelline or omphalo- 
mesenteric veins, which empty into the sinus venosus. This also receives 
the blood from the systemic veins, and opens into the primitive cardiac 
auricle. From the ventricle the blood passes through the tr uncus arte- 
riosus and the aortic arches to the primitive aortse, whence it is returned 
through the vitelline or omphalo-mesenteric arteries to the vascular area, 
and to a limited extent to the body of the embryo. 

Following the development of the allantois and the placenta the cir- 
culation becomes more complex. (Plate VIII.) 

The blood is carried from the placenta by the single umbilical vein to 
the under surface of the liver, where it divides into two streams, one 
proceeding through the ductus venosus to the inferior vena cava, and 
thence to the right auricle of the heart; the other, being joined by blood 
from the portal vein, passes through the capillaries of the liver, and so 
on through the hepatic veins to the inferior vena cava and the right 
cardiac auricle. From the right auricle the blood is directed by a fold 
— the Eustachian value — through the foramen ovale to the left auricle. 
Here it meets with the current from the pulmonary veins, and is passed 
through the auricular-ventricular opening into the left ventricle, and 
thence to the aorta and the branches of the systemic vessels. From the 
head and upper extremities the blood is collected by the superior vena 
cava and, passing directly through the right auricle, enters the right 
ventricle, by which it is forced into the pulmonary artery. Just outside 
the lungs, however, the stream divides, a small portion only going to 
these organs, the greater part turning off through the ductus arteriosus 
to the aorta. From the aorta most of the blood passes through the 
hypogastric arteries back to the placenta, a small amount going to the 
lower portion of the embryonic body and extremities. (Plate IX., A,) 

Changes in Circulation at Birth. By the third or fourth day after birth 
the hypogastric arteries have dwindled and become obliterated; by the 
end of the first week the umbilical vein and the ductus venosus are 

7 






PHYSIOLOG P OF PREGNANCY. 



closed] and by the end of the third week the ductus arteriosus has 
become impervious. The foramen ovale usually dose- soon after birth, 
but it may remain patent as a diminutive aperture during the firsl pear, 
or even throughout life, A persistent opening of the foramen results 
in an admixture of the venous and arterial blood in the auricles, which 
rives rise to a general blueness of the surface of the body, a condition 

known in the infant as cyanosis neonatorum, and in the adult as morbus 
ceruU us. 

As the result of the obliteration of the vessels mentioned the blood 
from the cava, superior and inferior, passes from the right auricle to 
the right ventricle, from by the pulmonary artery to the lungs, from 
which it is returned by the pulmonary veins to the left auricle, and so 
on to the left ventricle, by which it is forced into the dorsal aorta and 
distributed to the trunk, head, and extremities. The adult circulation 
is thus established. (Plate IX., B.) 

The Central Nervous System. Before the closure of the cephalic end 
of the neural canal has taken place, the beginning of the future brain is 
indicated. (Fig. 83.) 

Fig. 83. 

_,..-- Fore-brain --..^ 




Optic vesicle 




Inter-brain 

Mid-brain 

Hind-brain 

After-brain 



Diagram showing formation of brain (after Bonnet). 
I-III. Primary cerebral vesicles. 




Optic vesicle 



The anterior end of the medullary tube enlarges, and at two points its 
walls become constricted, giving rise to three communicating cavities, the 
primary cerebral vesicles, known as the fore-brain, mid-brain, and hind- 
brain. At about the same time that the cerebral vesicles are forming, 
the cephalic portion of the neural tube becomes bent as the result of the 
unequal growth of the parts. (Fig. 84.) The first of the cerebral 
flexures — the primary head-bend — takes place in the region of the mid- 
brain, the fore-brain being forced ventrad so that it comes to lie at a 
right angle to the mid-brain, the latter being carried forward and 
upward to the top of the head. The second, or neck-bend, occurs at the 
union of the hiud-brain and the spiual cord, the whole head being 
thereby thrown further forward and downward, so that the floors of the 
fore- and hind-brains become parallel. The third bend — the varolian 
bend — affects the hind-brain, and consists in a forward growth of this 
vesicle. 

With the beginning expansion of the fore-brain two lateral outgrowths 



^ 



b3 





-d 
r 

> 

W 

>-^ 
X 



DEVELOPMENT OF THE OVUM. 99 

— the optic vesicles — make their appearance. These soon become par- 
tially constricted off from the fore-brain, their narrow pedicles — the optic 
stalks — being the prota of the optic nerves. The dorsal wall of the fore- 
brain continues to grow forward and upward from the rest of the vesicle, 
and soon forms a fourth ventricle or permanent fore-brain, the proton of 



Fig. 84. 



f Mb 



Hb 



( 11 'tTJ^OP 1 | 

Brain of human embryo of five weeks, illustrating cerebral flexures (after His). 
H. Hemisphere. Mb. Mid-brain. Hb. Hind-brain. R. Olfactory lobe. OP. Optic nerve. Sp.c. 

Spinal cord. 

the cerebral hemispheres. (Fig. 85.) The original portion of fore-brain 
is now called the inter-brain ; its cavity becomes the third ventricle of 
the adult brain, while the opening between it and the permanent fore- 
brain is the future foramen of Monro. 

The second cerebral vesicle, mid-brain, develops more slowly than the 
other portions of the brain, which soon overgrow it, forcing it down- 
ward and backward. Its walls gradually thicken, while the cavity 
remains practically unchanged as the aqueduct of Sylvius. From the 

Fig. 85. 
177. Zh Z ? Mh Hh 



Diagram to illustrate the formation of the primitive brain (after Bonnet). 
bo. Olfactory bulb. Vh, Secondary or permanent fore-brain. Zh. Inter-brain. Zi. Epiphyses, i. 
Infundibulum. h. Hypophysis. Mh. Mid-brain. Hh. Hind brain. Nh. Medulla or after-brain. pV. 
Pons Varolii, to. Olfactory tract, es. Corpus striatum, ch. Chorda dorsalis. 1, 2, 3 correspond to the 
three primitive cerebral vesicles. 

roof of the mid-brain the corpora quad rig emina are developed, and in 
connection with its floor the crura cerebri. 

The hind-brain, which at the time of the cerebral flexures is the 
longest part of the brain, soon becomes differentiated into two parts, an 
anterior, from the roof of which is developed the cerebellum, and from 
the apex of the floor (varolian bend) the pons Varolii ; and a posterior 



100 



PHTSIOLOQ V OF PREGNANCY. 



portion, from the thickened floor of which, between the pons and the 
spinal cord, arises the medulla oblongata. The cavity of the hind-brain 
becomes the fourth ventricle of the adult brain. As the result of growth 
and Local thickenings the various parts of the brain become differentiated 
from tin se primary structures. 

The Spinal Oord. The neural canal is at firsl a simple tube with 
ectodermal walls. (Plate V., .V Figs. 6, 8, and 9.) In the devel- 
opment of the spinal cord the sides of the tube become thickened, but 
the dorsal and ventral portions remain thin. The central lumen thus 
becomes narrowed. At a late period the sides arc differentiated into 
the (inferior, lateral^ and posterior column* of the cord. The anterior 
median fissure is developed by the forward growth of the ventral por- 
tions of the cord, while the posterior median fissure represents the ob- 
literated posterior end of the central canal. 

Up to the fourth month the cord equals in length the vertebral col- 
umn, and extends from the first cervical to the last caudal vertebra. 
(Plate X.) From this time on, however, the bony structures outgrow 
the cord, which appears shortened, and its lower end is drawn out into a 
line filament — the filum terminate. By the sixth month the cord ex- 
tend- only to the sacral canal; at birth it is at the third lumbar vertebra, 
while a year later it is at the first lumbar vertebra, where it remains. 



Fig. 86. 




Transection through the spinal cord of a twenty-two days old sheep embryo (after Bonnet). 



The cord at first consists of gray matter, but with the development of 
the nerve-fibres, the white matter appears as a differentiation of the 
external cell-layer of the cord. 

Two sets of nerve-fibres develop from the cord : motor fibres from the 
nerve-cells of the inner layer, and sensory fibres from the spinal ganglia. 
(Fig. <S6.) The most rapid growth in the nerves takes place in the neck 
region, where they arise from the cord at right angles. Lower down, as 
the result of the superior growth of the vertebral column, the nerves 
gradually assume a vertical directiou, and remain for some distance 
within the spinal canal before making their exit. The lower bundle of 



PLATE X. 



III. IV. V.VIVc.VII. 
{VIIL 

I 




N.21 



Diagramatie Representation of a Human Embryo estimated as 

Thirty-one Days old, showing Brain, Spinal Cord 

and Nerves. (Modified from His.) 

H, cerebral hemispheres ; Th, thalmencephalon ; MB, mid-brain ; Su, sinus preeerviealis ; H.M, 
hyomandibular cleft (external auditory meatus) ; OF, olfactory pit ; V.b, maxillary branch of fifth nerve 
(trigeminal); Ol, olfactory lobe; Oc, optic cup; Gc, ciliary ganglion; III, third cranial nerve ; IV, 
fourth cranial nerve ; O, ophthalmic branch of fifth nerve ; V, Gasserian ganglion ; Vc, mandibular branch 
of fifth nerve ; VII, ganglion of seventh nerve (facial) ; VIII, ganglion of eighth nerve (auditory) ; Av, 
auditory vesicle; IX, ninth nerve (glossopharyngeal); X, ganglion of root of tenth nerve (pneumogas- 
tric) ; XI, roots of eleventh nerve (spinal accessory) ; XII, roots of twelfth nerve (hypoglossal) ; FG, 
Froriep's ganglion ; Xi, ganglion of first cervical nerve; X 9, ganglion of first thoracic nen-e ; N.H, 
phrenic nerve ; X 21, ganglion of first lumbar nerve ; N 26, ganglion of first sacral nerve ; X 31, ganglion 
of first coccygeal nerve ; T, tail ; VI, vitelline loop of intestine ; L,, Liver; V, ventricle ; A, auricle. 



DEVELOPMENT OF THE OVUM. 



101 



nerves surrounding the filnm terminate thus presents a brush-like appear- 
ance; this has given rise to the name cauda equina. 

Organs of Special Sense. The Eye. The development of the optic 
vesicles as outgrowths of the fore-brain has already been described (see 
Fig. 83). When the vesicles reach the ectoderm a close attachment is 
formed between the two, and the walls of each increase in thickness at 
the point of contact. The ectoderm then becomes invaginated, forming 

Fig. 87. 



PRIMARY^-- 
OPTIC CUP 




SECONDARY 
OPTIC CUP 





Diagrams illustrating the formation of the optic cups and lens. (Kolliker after Remak.) 

Fig. 88. 



V 1 




y 



Section through the eye of a calf emhryo. (After Kolliker.) 

the primary optic eup, the invagination continuing until a vesicle has 
become constricted off the proton of the lens. (Fig. 87.) In front of 
the lens-sac the edges of the ectoderm unite and, together with the meso- 



102 



PHYSIOLOGY 01 PREGNANCY. 



derm, which baa grown in between the lens and the ectoderm, form the 
proton "f the oornea. (Fig, 87. 1 A.e the result of the invagination of 
the ectoderm, the wall of the optic vesicle is also pushed inward, forming 
mdary optic oup, the doubled-in wall of which unite- with the pos- 
terior wall ox the optic vesicle to form the retina, the posterior layer of 
the wall furnishing the future pigmeitied layer. 

The space between the retina and the lens develops the vitreous /minor, 
while by the splitting of the mesoderm between the lens and the ecto- 
derm the anterior oharnber of the eye is formed, and later becomes filled 

with aqueous humor. 

The tissues about the optic vesicle thicken into a capsule which ulti- 

FlG. 89. 




Embryo of second day, showing otic pit (o). (After Kolliker.) 

mately becomes the sclera and the choroid. The opening of the second- 
ary optic cup is filled by the lens, the edges of the cup giving rise to the 
iris, while the central aperture becomes the pupil. 

The doubling in of the optic vesicle extends also to the stalk, along the 
ventral side of which a groove is formed, the choroidal fissure. This 
fissure closes about the seventh week by the fusing of its lips, but before 
this has taken place, an artery — the arteria centralis retina? — has made 
its way along the groove, penetrated the vitreous humor, and sent off 
branches to the lens. The anterior portion of the artery becomes oblit- 
erated during the last month of foetal life. The optic stalk is after a 



DEVELOPMENT OF THE OVUM. 



103 



time converted into a solid rod, which acquires nerve-fibres from both 
the brain and the retina, and becomes the optic nerve. 
Fig. 90. Fig. 91. 



Rec. 





Fig. 90.— Left otocyst of a human embryo of about four weeks. (Minot after W. His, Jb.) 
Rec. Recessus vestibuli. V. Vestibular region. C. Cochlea region. 

Fig. 91.— Left otocyst of a human embryo of about five weeks. (Minot after W. His, Jr.) 
Se. Saccus endolymphaticus. cs. Upper, ex. Lower, cfis. Horizontal semicircular canal. Ut. 
Utriculus. Sac. Sacculus. cch. Cochlea. 

Fig. 92. 




KK 

Section through the labyrinth of ear of sheep embryo. (After Bottcher.) 

Rl. Recessus labyrinthi : vertical and horizontal canals. U. Utriculus. s. Sacculus. 

Or. Canalis reuniens. Be. Ductus cochlearis. KK. Cartilage. 

The eyelids arise early as upper and lower folds of integument in front 
of the eye. The edges of the lids grow toward each other, meet and 
fuse, but again become separated shortly before birth. 



L04 



PHTSIOLOG P OF PREGNANCY. 



T/<< Ear, The development of the ear differs from that of the eve in 
i li.it it is an ectodermal structure entirely separated from the brain. 

Internal Ear, The first indication of the ear appears about the 
fifteenth dav as a thickening of the ectoderm just above the first gill-cleft 
Fig. 89. I'»v invagination of this thickened patch a sac is formed, the 
audit* ' or otocy at, which grows inward and becomes entirely sepa- 

rated from the ectoderm. At first the otocyst is spherical in form, but 
it Boon becomes pear-shaped (Fig. 90) as the result of the development 
of a projection, the rec€88U8 labyrinthi, from its dorsal side. Jiv the 
sixth week the otocysi has been converted by a fold into two portions — a 
dorsal part — the utriculu8 f from which three projections arise, the prota 



Fig. 93. 




f-Op 

Development of external ear. (After His.) The figures refer to the auditory tubercles. 

Fig. 94. 





Development of the human external ear. (After His.) 
1. Tragus. 2, 3, c. Helix. 4. Anthelix. 5. Antitragus. 6. Tenia lobularis. 

of the semicircular canals (Fig. 91), and a ventral part, the sacculus, 
from the anterior end of which the cochlea is developed. 

The lower proximal portion of the recessns labyrinthi is also converted 
into two tubes, which open into the sacculus and the utriculus respectively. 
(Fig. 92.) The complicated specialized portions of the internal ear arise 
as differentiations of the ectodermal lining of the structures. 

Middle Ear. The tympanum is developed from the membrane closing 
the first gill-cleft (hyomandibular pouch); the part within giving rise to 
the Eustachian tube and the tympanic cavity, which are lined by entoderm, 
the part without, to the external auditory meatus, being lined by ectoderm. 

External Ear. This is developed from six auditory tubercles which 



DEVELOPMENT OF THE OVUM. 



105 



appear about the external meatus, two from the posterior edge of the 
first branchial arch, one intermediate, and three behind the first gill-cleft. 
(Fig. 93.) The first tubercle becomes the tragus, the second and 
intermediate fuse to form the helix, the fourth gives rise to the anthelix, 
the fifth to the antitragus, and the sixth io the lobe. (Fig. 94.) Very 
little is known regarding the development of the tactile sense; the other 
two organs of special sense will be described elsewhere. 

The Alimentary Tract. From the three portions of the primitive enteron 
already mentioned are developed the pharynx, oesophagus, stomach, and 
intestines, and in connection with them the lungs, liver, and other tho- 
racic and abdominal organs. 



Fig. 95. 







Embryo of four weeks. (His.) 

1. Cervical spine. 2. Gills (aural opening). 3. Mouth Assure. 4. Nostrils. 5. Amnion. 

6. Chorion and villi. 

The Ifouth. In the development of the mesoderm a space, the pro- 
amnion (Fig. 59), is left in front of the head end of the embryo in which 
no mesoderm appears, the ectoderm and entoderm being closely united 
at this point. By the formation of the cephalic fold and the bending of 
the head, this point of union of the two layers, known as the oral plate, 
is carried downward to the ventral side of the head, and comes to lie at 
the anterior end of the fore-gut, occupying all that space between the 
fore-brain and the heart. The forward growth of both the fore-brain 
and the heart gives rise to a depression or pit between them, at the bottom 
of which lies the oral plate. (Plate V., Fig. 7, m.) The sides of the 
depression are formed by a layer of somatopleure which extends from 
heart to head, and afterward gives rise to the cheeks. 



L06 



rilYsioLOcy or J'REGNASCV. 



\\\ the niptm-c of the <»ral (date a direct communication between the 
l»it <>r oral cavity and the fore-gut is established. 

Tkt Pharynx. The anterior portion of the fore-gut, which from the 
first i- the widest part of the primitive enteron, -till further dilates at its 
distal cud, thus converting the tubular canal into a funnel-shaped cavity 
the future pharynx. This portion of the primitive gut ha- no coelom 
Burrounding it. 

At the beginning of the third week the entoderm of the sides of the 
pharynx develops a series of four paired pouches, the branchial^ visceral, 
or gill-clefls (Fig. 95), which grow outward to the ectoderm and unite 
with it. The anterior pair of gill-clefts appear at about the level of the 
mouth, and are followed by the other three pairs in regular order. 
Meanwhile the tissues from the three primary layers along the sides of 



FlQ. 96. 



Fig. 97. 




Fig. 96.— Frontal construction of the mouth and pharynx. (After His.) 

Fro. 97.— Frontal construction of the mouth and pharynx, showing development of nose and lungs. 
(After His.) 

the pharynx develop into five ridges between the clefts — the branchial, 
visceral, or gill-arches, which project quite freely from the surface both 
internally and externally. (Figs. 96 and 97.) 

The first visceral, or mandibular, arch, as it is afterward called, forms 
the lower boundary of the mouth, and is developed into the inferior 
maxilla. From this arch a process, called the maxillary process, is given 
off on either side, and these processes uniting at their distal ends form 
the upper boundary of the mouth. The second and third arches give 
rise to the hyoid and thyro-hyoid. bones ; the fourth and fifth arches have 
no particular significance, eventually disappearing. 

From the first gill-cleft are developed the Eustachian tube and the 
tympanic cavity ; from the second the tonsils ; while the third and fourth 
clefts are concerned in the formation of the thymus and thyroid glands. 



DEVELOPMENT OF THE OVUM. 



107 



The Nose. At an early stage a thickening of a patch of ectoderm in 
contact with the fore-brain and lying cephalad to the mouth gives rise to 
the olfactory plates. (Fig. 93, Op.) By an upgrowth of the ectoderm 
and mesoderm around the plates they are converted into the nasal pits, 
the lower sides of which remain open as a groove communicating with the 
mouth cavity. A tongue of tissue — the nasal process (Fig. 97, a) — now 
develops from the anterior wall of the head, and as it grows downward 
toward the mouth sends out on either side a rounded protuberance, 
the processus globular i (Fig. 97, 6), which unites with the maxillary pro- 
cess. The nasal grooves are thus converted into canals, the posterior 
nasal passages, leading from the pits to the mouth. Later the nasal 
pits become the narrow, slit-like apertures of the anterior nares. The 
alo3 nasi arise from the growth of the lateral margins of the pits. The 
Schneiderian membrane is evolved from the epithelium of the olfactory 

Fig. 99. 




Small in- 
testine 

Vitelline 
duct 



Greater curva- 
ture 



Greater omen- 
tum 



Place wheret he 
intestines cross 

Large intestine 



Rectum 



Duodenum 




Greater omen- 
tum 



Placewhere the 
intestines cross 



Mesocolon 
Large intes- 
tine 

Small intestine 



Rectum 



Diagrams illustrating the development of the stomach, intestine, omentum, and mesentery. 

(After O. Hertwig.) 



plates, and at a later period is brought into relation with the olfactory 
lobes of the brain by means of ganglia which develop from its epithelium. 

The Tongue. The anterior portion of the tongue arises as a small 
tubercle from the floor of the pharynx, between the second and third 
arches, the ends of which fuse to form the proton of the back of the 
organ. The lingual epithelium is of ectodermal origin; the papillae 
develop late, and from them the taste-bulbs. 

The oesophagus is that part of the fore-gut lying between the pharynx 
and the stomach. During the fourth week, as the neck elongates the 
oesophagus is rapidly stretched out to a considerable length, but it still 
retains its cylindrical form. 

The stomach appears during the fifth or sixth day as a slight dilatation 
of the primitive enteroa between the oesophagus and the liver. (Figs. 
102 and 103.) It soon shifts its position to below the liver. During the 
fifth week it becomes more pyriform in shape, and assumes a transverse 
position in the bodv, its left side coming to the front, while its right side 
is turned backward. During the change in position of the stomach its 
attachment to the dorsal body- wall becomes stretched out as a thin mem- 
brane — the mesogastrium — which, as the stomach rotates, forms a double 






PHYSIOLOQ V OF PREQ VANCY. 



fold, that pari of the membrane along the greater curvature of the 
stomach giving rise to the greater omentum, while that from the smaller 
curvature becomes the lesser omentum, (Figs. 98 and 99.) 

The intestine includes all of the alimentary canal between the stomach 
and the anus. At first it is a straight tube, but as the result of rapid 
growth it soon becomes coiled in order to accommodate its increasing 
length within the abdominal cavity. A duodenal loop (Fig. 100) is 
formed just below the stomach, and lower down a vitelline loop, which 
i- in connection with the yolk-sac, appears. The lower portion of the 
intestinal canal enlarges and grows more rapidly than the upper part 
and forms the large intestine. The caecum appears about the fifth week 
as a protrusion from the distal portion of the vitelline loop near the 
yolk-stalk, and from it the vermiform appendix develops as a long and 
slender outgrowth. (Fig. 99.) The posterior end of the intestine 



Fig. 100. 



Fie. 101. 




Posterior W'all—\~ 
Dorsal Mesentery — -J 




Lig. Sttspenso rium 
HepatL 



Fig. 100.— Schematic illustration of the intestinal canal in a human embryo of the sixth week. 

(After Toldt.) 

Fig. 101.— Diagram illustrating the origin of the liver. (After 0. Hertwig.) 

sp. CEsophagus. kc. Lesser curvature, gc. Greater curvature, da. Duodenum, d 1 . Proton of 

small intestine, d-. Proton of large intestine, d 3 . Vitelline duct. mg. Mesogastrium. ins. Mesen- 

terium. in. Spleen, p. Pancreas, cl. Cceliaca. ao. Aorta, mei. Mesenterica inferior, etc. Aorta 

caudalis. r. Rectum. 



terminates in a wide dilatation — the cloaca — which forms the common 
receptacle for the excretions from intestines and bladder. 

As the intestine elongates and separates from its attachment to the 
body-wall, the mesoderm is drawn out as a thin membrane, which later 
becomes the mesentery. (Fig. 99.) About the fourth week an invagi- 
nation of the ectoderm takes place on the ventral side of the embryo 
opposite to the terminal portion of the cloaca, by which the ectoderm is 
brought into contact with the entoderm, the two layers giving rise to the 
anal plate (Plate V., Fig. 7, a), and the ultimate rupture of this plate 
forms a cloacal opening which afterward becomes the anus. 

The liver arises about the fifteenth day as a hollow diverticulum from 
the ventral side of the fore-gut just below the heart (Fig. 101), and almost 
immediately gives off a second evagination. (Fig. 102.) The walls of 
these pouches become greatly thickened, and their distal ends are sur- 



DEVELOPMENT OF THE OVUM. 



109 



Fig. 102. 



rounded by a mass of yolk-cells which become separated off from the 
rest of the yolk. A network of solid cords is next developed in the 
cell-mass, and these, acquiring a lumen during the fourth week, form the 
proton of the hepatic ducts. The meshes of the network are filled with 
bloodvessels. The liver enlarges rapidly, so that at birth its weight in 
proportion to that of the whole body is twice as great as in the adult. 
The canal of the original diverticulum becomes the common bile-duct 
(ductus communis choledochus), and from this, before the end of the fifth 
week, a bud is given off to form the gall-bladder. 

The pancreas is developed during the fourth week as a diverticulum 
from the dorsal side of the duodenum nearly opposite the liver evagina- 
tiou, and grows into the mesogastrium where it gives off branching buds. 
The duct opening into the intestine at first lies 
in front of the bile-duct, but subsequently runs 
parallel to the latter, and the two open into the 
duodenum by a common orifice. (Fig. 102.) 

During the second week the pulmonary or- 
gans appear as two diverticula from the ventral 
side of the oesophagus just above and behind 
the auricle of the heart. (Figs. 97 and 103.) 
At this point the oesophageal tube is compressed 
laterally, and still further caudad becomes pear- 
shaped, then triangular, and finally separates 
into three divisions or tubes, the posterior tube 
forming the oesophagus proper, and the two 
lateral tubes the bronchi. The slit-like aper- 
ture through which the pulmonary diverticula 
open into the oesophagus just behind the fourth 
branchial arch is the future glottis, while the 
part immediately caudad represents the trachea. 
By the repeated branching of the latter the 
bronchioles and the alveoli appear. 

The larynx arises as a widening of the upper portion of the trachea; 
and the epiglottis is developed from a small tubercle situated posteriorly 
to the tubercle for the tongue. 

The lungs project conspicuously into the body-cavity, and, growing 
dorsad and caudad, push the peritoneum before them in the form of 
pouches which become the pleural sacs. The epithelium lining the pul- 
monary tract is derived from the entoderm, while the spaces between the 
bronchioles are filled with bloodvessels and tissue of mesodermal origin. 

The Urogenital System. The first indication of the urinary organs 
appears about the fifteenth day as a pair of rod-like cell masses, probably 
of ectodermal origin, lying in the tissues, one on either side, between the 
myotomes and the somato-splanchnopleural junction, and extending from 
the region of the heart caudad. Each rod acquires a lumen and becomes 
the Wolffian duct. (Plate V., Figs. 8, 9, un.) The caudal ends of the 
ducts are at first blind, but by rapid lengthening they soon reach to the 
posterior end of the intestine and open into the cloaca. (Fig. 104.) About 
the eighteenth day a longitudinal ridge appears along the dorsal wall of 
the body-cavity on either side of the basal attachment of the mesentery. 
These ridges project into the body-cavity and constitute the Wolffian bodies. 




Diagram of liver proton. 

(After GotteJ 

Ig. Lung. St. Stomach. I. Liver. 

p. Pancreas. 



110 



PHYSI0L0G V OF PREGNANCY. 



Within the ridge on the mesenteric Bide a series of cord-like thickenings 
develop and, acquiring a central canal, grow toward the Wolffian duct 



FIG. 108, 





Diagram showing the development of the lungs. (After His ) 
Fig. 104. 

Genital glani—" " _ ** 

Wolffian body 



Wolffian duct 




Allantoic stalk 

Umbilical Artery — \-\ / / Uro-genital sinus 



Diagram of urogenital apparatus. (After Bonnet) 



Umbilical opening 




Allantoic stalk 



Wolffian duct 

Kidney proton 
Cloaca 



Anal groove 
Diagram of kidney proton and cloacal region. (After Bonnet.) 



DEVELOPMENT OF THE OVUM. 



Ill 



Fig. 106. 



into which they open as the Wolffian tubules. The distal closed ends of 
the tubules become dilated and then invaginate to form the Malpighian 
bodies; the glomeruli arise from the branches of the aorta which pene- 
trate the Wolffian body at an early period. The veins, as has been 
mentioned, empty into the cardinal vein. Early in the fourth week an 
evagination appears on the dorsal side of the Wolffian duct just above 
the termination of the latter in the cloaca. (Fig. 105.) The distal end 
of this diverticulum grows rapidly cephalad between the Wolffian body 
and the vertebrae until it reaches the head-end of the former, where it 
dilates and covers the Wolffian body dorsally, forming the proton of 
the kidney. The long canal opening into the Wolffian duct represents 
the future ureter, and its upper 
end, which becomes dilated, the 
renal pelvis. From the dilated part 
of the renal evagination branches 
are given off to form the urinary 
tubules, from the blind ends of 
which the Malpighian bodies arise. 
The kidneys are definitely formed 
by the end of the eighth week, at 
which time the resorption of the 
Wolffian bodies begins, all but the 
cephalic ends of the latter disap- 
pearing. The opening of the ureter 
is subsequently shifted from the 
Wolffian duct to the urogenital 
sinus. (Fig. 106.) 

The suprarenal capsules are de- 
veloped partly from the mesoderm 
and partly from branches arising 
from spinal sympathetic ganglia. 
That part of the allantois con- 
tained within the abdominal cavity 
and lying between the cloaca and 
the umbilicus gives rise during the 
second month to the urinary blad- 
der. The proximal portion of the 
allantois dilates into a spindle- 
shaped vesicle, the upper part of 
which dwindles and finally be- 
comes a cord — the urachus. The 
bladder is lined by entoderm and 
its walls are formed from the meso- 
derm. At the close of the fourth 
week there appears a band of thick- 
ened peritoneum (mesothelium) along 

the external lateral border of each Wolffian body, extending caudad to 
the cloaca. During the fifth week each band acquires a lumen which 
opens above into the body-cavity and below into the cloaca. These are 
the Midler ian ducts, the prota of the female internal organs of generation. 

At an early period there appears on either side along the dorsal wall of 




Diagram of urogenital and sexual organs. 
(After Gray.) 
The parts are shown chiefly in profile, hut the Miil- 
lerian and Wolffian ducts are seen from the front. 
3. Ureter. 4. Urinary hladder. 5. Urachus. ot. The 
mass of Diastema from which ovary, or testicle is 
afterward formed. TV. Left Wolffian hody. x. Part 
at the apex from which the coni vasculosi are 
afterward developed, w, w. Right and left Wolflian 
ducts, m, m. Eight and left Mullerian ducts unit- 
ing together and with the Wolffian ducts in ge, the 
genital cord. ug. Sinus urogeni talis, i. Lower 
part of the intestine, cl. Common opening of the 
intestine and urogenital sinus. co. Elevation 
which becomes clitoris or penis. Is. Ridge from 
which the labia majora or scrotum are formed. 



llli 



PHYSIOLOGY or PREGNANCY. 



the ooelom between the Wolffian body and the mesentery a small ridge 
which extends nearly the whole length of the abdominal cavity. (Fig. 
107.) Thia ridge is the genital fold, and is formed by the thickening of the 
peritonea] epithelium, which at this point is called the germinal epithelium, 
because from it are developed the egg-cells of the female and the sper- 
matozoa of the male. The middle portion of the ridge is the proton of 
the sexual gland — ovary or testis. At a later stage the caudal ends of the 
genital ridge draw toward the median line and unite to form the genital 
cord. The differentiation of the sex, which can be determined micro- 
scopically as early as the fifth week, depends upon the changes which take 
place in the sexual -land. 

[n the male the sexual -land becomes the testis. A network of epi- 
thelial cords is first formed, and embedded iu these are the primitive 




Me* 



Wolffian body, genital fold, and Miillerian duct of chick embryo, fourth day. (After Waldeyer.) 

Wd. Wolffian duct. Md. Muller's duct. E. Geuital epithelium. Ov. Primitive ova. 

Gl. Glomerulus. Mes. Mesentery. Cce. Coelom. 

sperm cells. The cords acquire a lumen and become the prota of the 
seminiferous tubules. They connect with the anterior tubules of the 
Wolffian body which grow into the testis during the fourth month, and 
anastomosing in various directions form the rete testis. (Fig. 108, .4.) 
The outer tubules of the Wolffian body serve as communicating channels 
with the Wolffian duct — vasa efferentia — the duct itself in its upper por- 
tion becoming the epididymis, and below the vas deferens. In the male 
the middle portion of the Miillerian duct disappears, the upper end in 
contact with the testis giving rise to the hydatid of Morgagni ; its lower 
part buried in the genital cord forms the so-called uterus masculinus. 

In the female the sexual gland becomes the ovary. The sexual cords 
from the genital rnesothelium, or, as they are called here, the cords of 



DEVELOPMENT OF THE OVUM. 



113 



Fflilger, contain the primitive ova which become surrounded and sepa- 
rated from one another by smaller cells, forming an epithelial boundary 
or follicle around each ovum. The tubules from the Wolffian body grow 
into the ovary in the same manner as into the testis, giving rise to the 
parovarium or organ of Rosenmuller. (Fig. 108, B.) The anterior por- 
tion of the Wolffian duct persists as the longitudinal duct of the paro- 
varium; its caudal end disappears, or remains as the duct of Gartner. 



Fig. 108. 



A. Male. 



B. Female. 



Hydatid 



Vasa efferentia- 



Duct of 
epididymis 



Wolffian duct 
(vas deferens) 



Mutter's duct 



Uterus masculinus- 
Genital Cord 




Fimbria 



Parovarium 



■Paradidymis 



Ovary 



Paroophoron 



Mailer's duct 
(Fallopian tube) 

Wolffian duct 
(duct of Gartner) 



Genital cord 




Uterus 



Vagina 



Diagram to illustrate the homologies of the sexual apparatus. (After Minot.) 

The upper portion of the Miillerian duct above the genital cord gives 
rise to the Fallopian tubes or oviducts. At first these tubes run parallel 
with the body, but later they assume an oblique and finally a transverse 
position in the pelvic cavity, as in the adult. The genital folds as the 
result of superior growth of the other parts of the foetus are also carried 
across the body-cavity, and thinning out give rise to the ligamenta lata 
or broad ligaments. 

The lower portions of the Miillerian ducts included in the genital cord 
fuse in their lower middle portions to form a single tube — the utero- 
vaginal canal, the upper part of which is differentiated during the fourth 
month into the uterine fundus and body, the cervix uteri appearing some 
time during the fifth month. The lower part of the canal dilates and 
becomes the vagina. 

About the fourth week a septum develops and divides the cloaca into 
two cavities, an anterior, the urogenital sinus (Fig. 106), which includes 
the openings of the allantois and the Miillerian ducts, and a posterior, 
anal opening. The further growth of this dividing wall carries the two 
openings more and more apart, and ultimately appears as the perineum. 



1M 



PHYSIOLOGY OF PMEGNANCY. 



The External Genitals. The development of the external genitalia is 
the Bame in both Bexee up to the ninth or tenth week. About the fifth 
week a Bmall projection — the genital tubercle — is funned by the thicken- 
in- of the anterior portion of the anal plate. This is the proton of the 



PlO. 109, 



Fig. 112. 




LOWER LIMB 
CLOACA 




CLANS CLITORIS 
GENITAL RIOGE 
L-GENITAL FOLD 
GENITAL FURROW 



Fir.. 110. 



Fig. 113. 




— GLANS PENIS 
ENITAL RIDGE 
GENITAL FURROW 
GENITAL FOLD 
PERINEUM 
ANUS 




CLITORIS 
GENITAL RIDGE 

GENITAL FOLD 
VESTIBULE 
OF VAGINA 
PERINEUM 
ANUS 



Fig. 111. 



Fig. 114. 



:\<s 



;>f :.:_JL 



• , 






: 



GLANS PENIS 
PREPUCE 

GENITAL FOLD 
GENITAL FURROW 



SCROTUM 



RAPHE OF 
SCROTUM 



PREPUCE 
LITORIS 
LABIUM MAJUS 

LABIUM MINUS 
VESTIBULE 
OF VAGINA 




Six stages in the development of the external genitals. (After Ecker-Ziegler models.) 



clitoro-penis. The tubercle later develops a head or glans, and a farrow 
— the genital groove — appears along its ventral side, running backward 
to the urogenital sinus. During the tenth week a slight elevation — the 
genital labium — arises on either side of the genital tubercle and extends 



DEVELOPMENT OF THE OVUM. 



115 



backward along the lateral margin of the urogenital sinus. Changes 
now take place which differentiate the male from the female organs. 

In the male the genital tubercle elongates and becomes the penis (Figs. 
109 to 111); and the furrow along its under surface is converted into a 
canal — the urethra — by the growth, apposition, and fusion of the sides of 
the groove. Their line of union is represented in the adult by the raphe 
penis. Toward the close of the fifth month the prepuce is developed as 
a fold of skin around the base of the glans. The scrotum arises during 
the fourth month by the meeting and fusion of the genital labia, which 
enlarge and grow downward between the root of the penis and the 
anus. 

In the female the genital eminence remains small and becomes the 
clitoris. (Figs. 112 to 114.) The genital groove is closed in to form the 
urethra, while its side folds develop to form the labia minora or nympho3. 
The genital labia give rise to the labia majora, the anterior extremities 
of which become the mons veneris or mons 'pubis. 

The Skeleton. The osseous system of the embryo is relatively late in 
appearing, the bones arising either from a preceding cartilaginous stage 
or independently in membrane. The notochord, the earliest indication 
of the axial skeleton, is first surrounded by a membranous sheath, out- 
side of which a cartilaginous tube is subsequently formed, and from this 
arise the bodies and processes of the vertebrae. Ossification takes place 
in each vertebra from three centres, 
one for each arch and one for the body, 
to which two more centres are added 
later for the epiphyses. 

The pelvis appears as a bar of carti- 
lage {ilium) on either side, articulating 
at the middle with the femur, and 
united at their ventral ends by con- 
nective tissue. The ischium and pubis 
arise ventrally from the acetabular re- 
gion and uniting at the symphysis en- 
close a space, the obturator foramen. 
By the end of the third month ossifica- 
tion begins from three centres, one for 
each bone, but the union of the three to 
form the innominate bone is not com- 
pleted until puberty. 

The extremities (Fig. 115) arise during the third week as bud-like 
outgrowths from a lateral longitudinal ridge extending along the ventral 
ends of the muscle plates for nearly the whole length of the embryonic 
trunk. 



Fig. 115. 




Development of the human anterior ex- 
tremities. (Allen Thomson, after His.) 
A. At four weeks. B. At five weeks. C. At 
seven weeks. D. At nine or ten weeks. 



in; 



rilYsioljx.Y OF PREGNANCY. 



EMBRYO AND FCETUS AT DIFFERENT PERIODS OF DEVELOPMENT. 1 

First month — viscera) arches and clefts readily distinguished. Spinal 
oanal closes. Bads of rudimentary extremities appear. Indication of 



i-i. ;. lit.. 



Flu. 117. 



Fiu. 118. 



i... ll'.t. 







Pig. 120. 



Fig. 121. 





Human embryos, first month. X 5. (His.) 
Fir;. 122. Fig. 123. 





Human embryos, second month. (His.) 

i On account of the great variance of tabulated observations and difference in the development of 
individual embryos of the same age, uniformity and accuracy in weights and lengths are impossible. 
After the second* month the weights and lengths given above in grammes and centimetres are taken 
from Hecker's well-known tables. The weights and lengths in grains and inches are from various 
English and American sources. They must be considered as only approximate. 



DEVELOPMENT OF THE OVUM. 



117 



eyes, anus, mouth. The heart is four-tenths of an inch long. (Figs. 116 
to 121.) 

Second month — about 2.5 cm., 1 inch long. The eyes, nose and ears 
are distinguishable. Suggestion of hands and feet. External genitals. 
(Figs. 121, 122.) 



Fig. 124. 




Nine weeks' embryo. Magnified four times. (His.) 



Third month — products of conception about the size of a goose-egg. 
Fingers and toes separated. Nails as fine membranes. Neck separates 
head from body. Sex distinguishable; uterus formed. Length, 4 to 
9 cm., 5 inches; weight, 5 to 20, average 11 grammes, 460 grains. 
(Fig. 124.) 

Fourth month — 10 to 17 cm., 6 inches, long; weight, 10 to 120, 
average 57 grammes, 850 grains. Short hairs, lanugo, present. Head 
equal to about one-fourth of entire body. 

Fifth month — 18 to 27 cm., 10 inches, long; weight, 75 to 500, 
average 284 grammes, 8 ounces. Vernix caseosa forming. Eyelids 
begin to separate. Heart-sounds perceptible. Quickening takes place. 



US PHYSIOLOGY OF rilKGNANCY. 

Sixth month — 28 to 3 I om., L2 inches, long; weight, 375 to 1280, 
average 634 grammes, 23] ounces. Hair on head. Eyebrows and 
lashes. Testicles near rings. 

Seventh month — 35 to 38 cm., L5 inches, longj weight, 780 to 2250, 
average 1218 grammes, 11.' ounces. Pupillary membrane disappears. 

Eighth month — 39 to 11 cm., 16 inches, long; weight, 1093 to 2438, 
average L 669 grammes, 3 \ pounds. Left testicle descended. Nails do 
nnt protrude beyond finger tips. Lanugo begins to disappear. 

Ninth month— 42 to 44 cm., 18 inches, long; weight, L500 to 2906, 
average 1971 gramme.-. \\ to 7 pounds. 

Tenth month — Lanugo almost entirely disappeared. Skin pink; flexor 
Burfaces covered with vernix; both testicles descended in males; labia 
majors in apposition in females; intestine contains abundance of 
meconium; eyes open. Length about 50 cm., 20 inches. 



CHAPTER III. 

CHANGES IN THE MATERNAL ORGANISM CAUSED BY PREGNANCY. 

The fixation of the impregnated ovum in the uterus begins a series 
of changes in the organs and structures immediately concerned in ges- 
tation, and also, though to less extent, in the organism at large. The 
changes which take place in the generative organs, being the most 
important, will first be considered. 

The Uterus, the normal site of pregnancy, is the seat of the principal 
alterations. These changes affect the size, shape, structure, position, and 
properties of the uterus. They begin at conception, and are for the most 
part progressive throughout the entire period of gestation. 

The first effects of pregnancy are to be observed in the uterine mucous 
membrane. The increased vascular supply which attends the fixation 
of the impregnated ovum in the uterus, instead of being followed by 
the ordinary destructive changes incident to menstruation, becomes the 
leading factor in a process of hypertrophy and hyperplasia in the mucosa, 
and results in the formation of the decidua. 

Size. Coincident with the development of the decidua begins a 
gradual growth in the size and weight of the uterus, which continues 
till the later weeks of pregnancy. In the virgin state the uterus meas- 
ures 7 cm., 2} inches, in length, 4.5 cm., If inches, in breadth, and 2.5 
cm., 1 inch, in thickness, and weighs about 42.5 grams, one and one-half 
ounces. During the ten lunar months of pregnancy it steadily develops, 
and at the end of that period it is a large, flaccid, vascular organ, measur- 
ing about 35.5 cm., 14 inches, in length, 25 cm., about 10 inches, in 
breadth, 24 cm., about 9 J inches, in thickness, and weighing a kilogram 
or more, two or two and one-half pounds. It has, therefore, increased 
in size some twenty-five times. In capacity it has increased from one 
cubic inch to four hundred cubic inches, and its internal surface is 
expanded from five or six square inches to three hundred and fifty 
square inches. 

Approximate Measurements of the Gravid Uterus at Different 
Periods of Pregnancy. 

Stage of gestation. Total length. Width. 

Twelve weeks 12 cm. 5 inches. 10 cm. 4 inches. 

Sixteen " 15 " 6 12 " 5 

Twenty " 18 " 7 15 " 6 

Twenty-four week? . . . . 21.5" 8% " 16.5" 6% " 

Twenty-eight " . . . . 25 " 10 " 18 " 7 

Thirty-two " . . . . 29 " 11% " 20 " 8 

Thirty-six " . . . . 33 " 13 " 23 " 9 

Forty weeks ..... 35.5" 14 " 25 " 10 

Shape. The pyriform shape of the unimpregnated uterus is pre- 
served during the first three months of pregnancy. During the next 
two months the lower segment expands out of proportion to the growth 

(119) 



120 



PHYSIOLOGY OF PREGNANt V. 



of the upper segment, and the organ thus becomes more nearly spherical; 
finally, in the later months, the uterus again resumes its pyriform shape. 
In the intervals of contraction, the uterus is a simple sac with Quid con- 
tent-, but under the pre— ni - c <>f the abdominal walls it becomes flattened 
in its antero-posterior diameter, the width increasing at the expense of 
the Length. ^ 

Structure. The increase in the bulk of the uterus is mainly due 
ti> hypertrophy of it- structures, and in the later months in some degree 
to distention. During the first two or three months the growth is sym- 
metrical; later, the fundus and body grow more rapidly than the cervix. 
First occurs a thickening and softening of the mucous membrane, which 
also becomes more vascular. Similar changes take place in the paren- 
chyma of the organ, owing to hyperplasia of the muscular and connec- 
tive-tissue elements, and of an increase in the number and size of the 
bloodvessels, lymphatics, and nerves. In the later months of pregnancy 
the walls become thinner, till at term they measure from one-sixth to 
one-fourth of an inch in thickness. This thinning of the uterine walls 
is the result of stretching, from the distention of the organ by its grow- 
ing contents. The growth of the uterus in the later months of pregnancy 
is largely by dilatation. 

During gestation the non-striated muscular fibres which make up the 
bulk of the uterine walls are enormously developed, some of them becom- 
ing eleven times longer and five times broader than in the unimpregnated 
state. (Fig. 125.) In advanced pregnancy three muscular layers are easily 



Fig. 126. 



Fig. 126. 





Muscular fibres of uterus 
during gestation. (Wagner.) 



External muscular coat, anterior aspect. 

(ilENLE.) 



differentiated. The external layer is thin, and intimately adherent to the 
peritoneum. (Fig. 126.) The middle layer forms the bulk of the uterine 
walls, and is composed of circular fibres surrounding the vessels and of 
longitudinal fibres interlacing with one another. (Fig. 127.) The inner 
layer, also thin, is composed mainly of circular fibres concentrically 



CHANGES IN THE MATERNAL ORGANISM. 



121 



arranged around the os internum and the orifices of the tubes. (Fig. 
128.) Clinical evidence indicates the existence of a sphincter muscle 
at the os internum; but anatomists are not yet decided upon this point. 



Fig. 12 




Middle muscular coat at fundus, where the placenta was seated. The crossing fibres form rings 

around the vessels which constrict them. (Henle.) 

a, a, superficial layer dissected back ; b, bundles belonging to the inner layers ; t, t, tubes. 



Fig. 128. 



The uterine wall, instead of being hard and firm to the sense of touch, 
as in the non-pregnant state, becomes so soft and elastic that the foetal 
parts can be felt through it. 

The arteries become larger and longer, and in places they empty 
directly into the veins. 

The veins dilate into large channels called sinuses. So closely united 
are they with the surrounding connective tissue that when cut they do 
not collapse. The sinuses are largest 
within the placental area. 

The lymphatics participate in the 
general hypertrophy of the uterine 
structures; starting from the deeper 
portion of the mucous membrane 
they traverse the muscular layers, 
and are gathered together in exten- 
sive plexuses, which are developed 
most abundantly over the fundus and 
sides of the uterus. 

The nerves likewise increase in 
length and thickness, and grow in- 
ward toward the uterine cavity. 
The cervical ganglion is more than 
doubled in size, and smaller gan- 
glia may be observed on the inner 
surface of the uterus. 

The growth of the uterus puts its 
peritoneal covering on the stretch, 
and, in places, the formation of new 
tissue elements causes a thickening 
of the serous membrane. 

Position. Concomitant with the changes already mentioned, there 
appear marked alterations in the position of the uterus, varying from 
time to time as pregnancy advances. During the first and second 




Internal muscular layer. (Henle.) 
a, section of uterine wall ; b, triangular bun- 
dle ; c, fibres running to the tubes ; d, d, orifices 
of tubes ; e, e, transverse fibres ; v, vagina. 



L22 



PHYSIOLOGY OF PREGNANCY. 



Fig. 129. 



months the increasing sise and weight of the organ cause it to assume a 
-nun -what lower position in the pelvic cavity, with hut little alteration 

of the Dormal axis. Bnl during the third month a still greater Increase 
in >ize and weight, in conjunction with the force of gravity acting upon 

the Upper end of the uterine lever, cause the fundus to fall forward, and 

a corresponding rise of the cervix to take place. There is an increase 

in the normal anteversiOD of the uterus. Since, during the first three 

months of pregnancy the enlargement is principally in the antero- 
posterior and lateral diameters, the uterus remains within the true 
pelvis, the fundus not rising above the symphysis pubis. In the early 
part of the fourth month the longitudinal increase becomes apparent, 
and the growing uterus can no longer be acommodated within its former 
boundaries; it begins to rise above the pelvic brim; at the fifth month it 
tills the hypogastrium, and at the sixth it reaches to the level of the um- 
bilicus. At about eight and one-half months the fundus is nearly in con- 
tact with theensiform cartilage. (Fig. 129.) Within the last two weeks 

of pregnancy the uterus sinks more 
deeply in the true pelvis, and assumes 
a lower position than before, the fundus 
resting downward and forward from 7 
to 8 cm., 2} to 3 J inches, below the 
ensiform cartilage. This sinking of the 
uterus is termed lightening. In pri- 
miparse the descent of the pregnant 
uterus within the true pelvis is more 
noticeable, because of the greater ri- 
gidity of the abdominal walls. The 
descent of the foetal head into the pel- 
vic brim during the last weeks of utero- 
gestation affords satisfactory evidence 
that the pelvic inlet is relatively am- 
ple. The position of the uterus is in- 
fluenced also by the posture of the 
woman. When she stands, the body of 
the uterus is supported by the anterior 
abdominal wall ; when she is in the 
recumbent posture, it rests against the 
vertebral column, with the fundus ap- 
proaching the diaphragm; when in a lateral posture, it gravitates to 
the dependent side. 

Properties. The foregoing changes in the uterus imply the assump- 
tion of new and unusual properties. The muscular walls, with their 
enormously hypertrophied fibres, are yielding and elastic. This elas- 
ticity permits of the movements of the foetal body common to this 
period of gestation. The uterus gradually acquires an increased irrita- 
bility, and responds more readily to stimulation of its muscular fibres. 
Growing contractility causes the physiological phenomena of painless 
and painful contractions common during the later weeks of pregnancy. 

The Cervix. Many varying opinions exist as to the part played by 
the cervix in the general uterine enlargement. Discussion in this place 
is unnecessary; it is sufficient to say that the weight of evidence favors 




Size of uterus at various periods of 
pregnancy. 



CHANGES IN THE MATERNAL ORGANISM. 123 

the belief that the cervix has a limited share in the formation of the 
fully developed body of the pregnant organ. As previously stated, 
during the first three months of pregnancy, the growth is about equal 
in all parts of the uterus, the cervix reaching a length of little more 
than 5 cm., 2 inches. During the seventh month the os internum 
expands into the adjacent uterine cavity, as a result of the pressure of 
the growing ovum, and the traction of the muscular bands passing from 
the outer layers of the uterus into the round and sacro-uterine ligaments 
— retractor fibres of Bayer. The hyperemia which attends the devel- 
opment of the cervix occasions a physiological softening of the tissues, 
manifested first in those portions of the cervix in which the least resist- 
ance is encountered, viz., under the mucous membrane at the os exter- 
num, and extending thence from below upward toward the os internum. 
The follicles of the cervical mucous membrane furnish an abundant 
supply of thickened secretion, filling the canal, and forming what is 
called the " mucous plug." The orifices of the mucous follicles fre- 
quently become occluded. The sacs then become distended with their 
own secretion, and project from the surface of the mucous membrane, 
forming the Nabothian ovules. The cavity of the cervix is dilated 
and funnel-shaped. 

During the later weeks of gestation, and at the end of pregnancy, as 
a result of these various changes, the cervix measures from one and one- 
fourth to one and one-half inches. Immediately before labor the vaginal 
portion of the cervix projects less and less into the vagina; the apparent 
shortening being due to the swelling of the vaginal walls and of the 
tissues at the junction of the cervix and vagina, and to the traction 
exerted by the longitudinal and diverging muscular fibres of the corpus 
uteri. In primiparse the changes in the cervix begin at an earlier 
period, owing to the greater resistance of the tissues of the uterine body. 

The Adnexa. The folds of the broad ligament gradually become 
separated, and at the end of pregnancy the ovaries and Fallopian tubes 
are in close contact with the uterus. 

The Pelvic Peritoneum, in its relation and disposition, undergoes 
marked changes, in regard to which there is not entire unanimity of 
opinion. It is obvious that the peritoneum on each side of the uterus 
must be elevated to a considerable extent during pregnancy, but with 
reference to the peritoneum covering the anterior and posterior fossse-r- 
the vesico-uterine cul-de-sac and that of Douglas — there is some differ- 
ence of opinion. Polk holds that these, too, are raised by the mechan- 
ical action of the uterus during its growth, which at the same time strips 
the peritoneum from the bladder. On the other hand, the observations 
of Webster on frozen sections seem to prove that the floors of the two 
fossa? mentioned are as low during pregnancy as in the nulliparous state. 
According to the latter author, the bladder is stripped of its peritoneum 
by the sinking of the pelvic floor. 

The Vagina partakes of the increased nutritive activity of pregnancy. 
Growing vascularity causes thickening and softening of the mucous 
membrane, which furnishes a more abundant secretion. The enlarged 
vessels of the venous plexus impart a bluish or violet color to the 
vagina. The vagina is increased in length, and though it is drawn 
upward by the uterus during pregnancy, the anterior wall frequently 



\-2\ PHYSIOLOGY OF PREGNANCY. 

protrudes from the vulva. The swollen papilla cause the mucous mem- 
brane to present a granular feel to the examining finger. 

The External Genitals share in these changes. The largely devel- 
oped bloodvessels and lymphatics and the increased vascular tension 

induce a condition of Bbftening and infiltration which causes the vulva 
to gape and to appear particularly prominent. The venous turgescence 
gives to the vulva a dusky hue. The increased vascularity results in a 
condition of great functional activity on the part of the sweat-glands 
and sebaceous follicle-. 

The Pelvic Floor undergoes a downward displacement during preg- 
nancy, which by the end of gestation results in nearly doubling the 
skin-distance from symphysis to coccyx. 

The Articulations of the Pelvis are softened by an increased vascularity 
of the inter-articular cartilages. The symphysis pubis is the joint most 
affected ; it is to an extent loosened, thus permitting a limited degree 
of mobility toward the end of pregnancy. As a rule, these changes in 
tin' articulations contribute very little to the enlargement of the pelvis. 
Should they become pronounced, they may give rise to great incon- 
venience in locomotion. The sacro-coccygeal articulation is mobile in all 
women during the first fifteen years of the child-bearing period, and 
during the expulsion of the child permits recession of the coccyx to the 
extent of one inch. 

General Changes. Pregnancy is the cause of numerous and impor- 
tant changes in the maternal organism at large. Although different 
parts of the body and numerous physiological functions are involved, they 
are not all equally affected. These changes are manifest particularly 
in the nervous and the circulatory systems. Pregnancy being a physi- 
ological process, the organism displays great adaptability in meeting 
these changed conditions. The pregnant woman breathes, provides nour- 
ishment, secretes and excretes not only for herself but for the growing 
foetus as well. The normal woman is perfectly able to meet these addi- 
tional demands when occurring within certain limits, beyond which 
disturbances of health are likely to supervene. In most instances there 
is an apparent improvement in the general health during gestation, as 
though an extra store of energy were being accumulated for the coming 
ordeal of parturition. 

Circulatory Changes. Headaches, ringing in the ears, flushed 
face, cardiac palpitation, and dyspnoea, which are common symptoms of 
pregnancy, led the older practitioners to think that there was present a 
condition of plethora, in consequence of which, thirty-five years ago, 
it was a common practice to perform venesection upon pregnant women. 
Now that the blood conditions are better understood, such practices 
have very properly become obsolete. 

The blood is somewhat altered in composition and increased in quan- 
tity. Extreme changes, formerly believed to take place, do not occur in 
healthy gravida. During pregnancy the watery elements and the pro- 
portion of white corpuscles are increased. In general, the albuminous 
constituents are diminished. After parturition large quantities of excre- 
mentitious material, from both the foetal and the maternal organisms, 
are thrown into the blood. It is reasonable that the blood should be 
increased in quantity during pregnancy, for the amount necessary before 



CHANGES IN THE MATERNAL ORGANISM. 125 

gestation would be inadequate to meet the additional requirements of 
foetal nutrition. The condition is not a true plethora, but simply an 
increase in the amount of serum. The diet of the pregnant woman, as 
well as her hygienic surroundings, profoundly affect the quality of the 
blood. Unsuitable diet and unhygienic surroundings may cause a 
condition of marked anaemia and hydrsemia. The extra nutritional 
demands must be met by careful attention to the two elements men- 
tioned. Changes in the blood are most pronounced at the close of ges- 
tation, and are often evidenced by thrombotic tendencies at this time and 
shortly after labor. 

The heart undergoes hypertrophy, another example of Nature's 
adaptability, to meet the increasing demand upon the circulation as 
pregnancy advances. Although the weight of this organ is increased 
one-fifth during the pregnant state, the left ventricle is alone affected, 
for upon it the additional work is largely thrown. This physiological 
hypertrophy continues daring the period of lactation, but in women who 
do not suckle, the heart quickly returns, as a rule, to its normal size. 
In women who are repeatedly and frequently pregnant, the heart remains 
in some degree permanently enlarged. As a consequence of the largely 
augmented pelvic circulation, it follows that the heart must act more 
rapidly than in the non-gravid state. The arterial tension is increased, 
imparting greater fulness to the pulse. 

Disturbances often follow these changes in the circulatory system. 
At first, palpitation is purely sympathetic in character, but latterly the 
pressure on the diaphragm from the growing uterus interferes directly 
with the heart's action. (Edema not infrequently results from the alter- 
ations in the character of the blood. 

The spleen increases in size, as does also the liver. Fatty degenera- 
tion occurs in both viscera. The thyroid gland, by reason of its nutri- 
tional and circulatory relations, undergoes an increase in size, and in 
women who possess a tendency to enlargement of this gland, pregnancy 
may still further stimulate its growth. 

Respiratory Changes. The enlarging uterus acts mechanically to 
modify respiratory movements. Upward pressure upon the diaphragm, 
reducing the longitudinal diameter of the chest, prevents free respiratory 
action, notwithstanding the fact that the transverse diameter of the lower 
thorax is increased. As the end of gestation approaches, the uterus 
sinks slightly, thus materially relieving the hitherto embarrassed circu- 
lation and respiration. Since, during pregnancy, the quantity of blood 
to be purified is increased, it follows that there must be an increase in 
the amount of carbonic-acid gas excreted by the lungs. Cough and 
dyspnoea may be entirely sympathetic when occurring during the early 
months of pregnancy, but in the later weeks there exists a distinct 
mechanical cause for such symptoms. Such evidences of disturbance are 
more frequently the result of a twin pregnancy, or of amniotic dropsy. 

Nutritional and Digestive Changes. Upon the digestive sys- 
tem rests the responsibility of providing nutritional elements to meet the 
greater demand. Larger quantities of food are required, and it follows 
that there must be an increase in digestive activity, as well as additional 
work for the excretory organs to perform. Digestive disturbances, 
including nausea and vomiting, are so common in the early months as to 



[26 PHYSIOLOG V OF PREGNANCY. 

be an almost constant concomitant of pregnancy. They are present in 
tin* vast majority of cases during the second and third months, gradu- 
ally disappearing as pregnancy advances. With their cessation, appetite 
usually returns, the digestive activity is increased, and there is marked 
improvement in the general nutrition. Irrespective <>f the growing 

ntcrn- and ovum, and often even despite nau-ea and vomiting, there i- 

normally a steady gain in body-weight. Although constantly progres- 
sive, the gain i- most marked in the last two month-, and for the entire 
period ,»t' gestation it amounts to from ten to fifteen pounds. The fat i< 

the tissue most largely increased; it is deposited particularly in the mam- 
mary glands, abdominal parietes, and omentum. The figure becomes 

fuller and rounder. This increase of stored potential energy is to be 
utilized after delivery, when the physical powers are taxed by lactation. 

PUERPERAL ()>ti;orhytes sometimes develop on the inner sur- 
face of the frontal and parietal bones. They are irregular in outline 
and are composed of calcium carbonate, traces of phosphates, and organic 
matter. They are not peculiar to pregnancy, and may sustain some 
relation to the calcareous changes in the placenta and to the forthcoming 
milk secretion. 

There is no material alteration of the body temperature during preg- 
nancy. 

Changes in the Skin, the Gait, and the Osseous System. 
The hair follicles, the sebaceous and sweat glands are more active during 
pregnancy. It has been stated that the growth of hair is invigorated at 
this time. Pigmentations, occurring in isolated patches over the body, 
are often observed; these are particularly noticeable upon the abdomen, 
the face, and around the nipples, the primary and secondary areolae. A 
dark pigmented line, the linea nigra, is frequently observed extending 
from the umbilicus to the symphysis, and sometimes continued to the 
ensiform cartilage. These pigmentations vary in different subjects, being 
more marked in brunettes than in blondes. After parturition they are 
diminished in intensity, but rarely disappear. 

In pregnancy there is a marked change in the gait and carriage, par- 
ticularly noticeable in short women. In order that the equilibrium may 
be maintained, the head and shoulders are thrown backward. 

Because of the drain on the osseous elements of the blood, a fracture 
occurring during pregnancy does not unite readily. 

Urinary Changes. The kidneys, which are supposed to be en- 
larged, furnish a more abundant supply of urine of a lower specific 
gravity. This functional activity is due to increased arterial tension. 
The qualitative changes in the urine are an increase in the chlorides, and 
a diminution of the phosphates and sulphates, which are used by the 
growing foetus. The pellicle, kiestein, often found upon the cold urine 
of pregnant women, is not peculiar to pregnancy; it is observed under 
other conditions, and even in the opposite sex. 

Sometimes lactose makes its appearance in the urine during the later 
weeks of pregnancy, and during beginning lactation. The proportion 
depends upon the relation of supply and demand, diminishing as the 
balance is established. 

The writer has determined by observation of a large number of cases 
that from 5 to 10 per cent, of pregnant women have albuminuria, usually 



CHANGES IN THE MATERNAL ORGANISM. 127 

small in quantity and extending over short periods only. It is more 
likely to be present during parturition than pregnancy, and is especially 
apt to follow a long and difficult labor. 

Changes in the Nervous System. Marked changes in the mental 
characteristics of the woman are common. She may become fretful, 
peevish, irritable, and at times unreasonable. The tendency to emo- 
tional disturbances is increased. The nervous system becomes extremely 
impressionable. Home surroundings, whether agreeable or not, may 
exert a profound influence, either for good or for evil. Slight ailments, 
which at other times would affect the nervous system but little, may 
have an exaggerated import. These symptoms may progressively increase 
in intensity till during the latter part of pregnancy, or soon after labor 
temporary or even permanent melancholia or mania may result. 



CHAPTER IV. 

DIAGNOSIS OF PREGNANCY. 

METHOD, clearness, and perspective are not more necessary to the 
student in Learning the signs of pregnancy than is the acquisition of a 
habit of orderly procedure to the practitioner in making a diagnosis of 
this condition. The difficult cases are many; the result of error is ridi- 
cule. Vander Veer has collected sixty-eight instances of operation on 
supposed pathological growths, some of the operators being men of note. 
The laity imagine that it cannot be hard to tell whether or not there is 
a child in the womb, and often insist upon a positive conclusion. This 
demand is strongest in the early weeks when the signs are fewest and 
faintest. A relatively large amount of space has, therefore, been accorded 
to the changes in the second and third months, and to their literature, 
whereas the later major signs are our common property, whose history 
may be omitted in this short chapter. 

In addition to the main question — whether certain indications are or 
are not present — the examination will necessarily touch on the possibility 
of the diseases that simulate each sign; the estimate of the period to 
which gestation has advanced, in order to collate all the signs due at 
that period, and the queries whether the pregnancy is normal or abnormal, 
the child alive or dead. Many other facts, very nearly connected with 
the subject-matter of this chapter, but more commonly inquired into a 
month before labor, are relegated to the antepartum examination, which 
may be found under the chapter on the Management of Labor. In quiz- 
zing, one asks concerning each sign: what its character is, its cause, the 
method by which it is brought out, its location, the date of appearance 
and duration, and what conditions other than pregnancy may counterfeit 
or develop it. Only through bedside instruction can the student learn 
the look of the areola or acquire skill in palpation and auscultation. 

The four steps of the examination follow an obvious order : History 
from the patient; physical exploration, mammary, abdominal, pelvic. 

I. History. 

The chief symptoms obtainable from the patient are cessation of men- 
struation, nausea, enlargement of the breasts and abdomen, and quick- 
ening. 

Suppression of Menses. After conception menstruation ceases. This is 
usually the first sign to draw attention to the condition. " In a woman 
of previously regular menstrual habit, and in the absence of other appre- 
ciable causes of amenorrhoea, the arrest of the catamenia is to be regarded 
as strong presumptive evidence of pregnancy.' n The importance of 

1 Essentials of Obstetrics, by Charles Jewett. Lea Bros. & Co., Phila., 1897. From this book the 
writer's classification is mainly drawn, with much more besides. 

(128) 



DIAGNOSIS OF PREGNANCY. 129 

this evidence increases after the second omission, since belated appear- 
ance of the flow for a few days to two weeks is not uncommon. It is 
most weighty, as indeed may be said of all the signs, when it corresponds 
in time with the size of the uterus and the usual date of appearance of 
the other evideuces of pregnancy. 

Three things lessen the value of this sign : 

a. There are other causes of amenorrhea. These are mainly anaemia, 
tuberculosis, chilling, delay in menstruation, emotional causes, nephritis, 
as well as change of climate, obesity, the menopause, pelvic inflamma- 
tions and tumors, and au irregular menstrual habit. Newly married 
women or those fearful of the results of wrong-doing are rather prone 
to run over their time; sea voyages check the flow with our immigrants, 
or the climacteric may arrive early. 

b. An apparent menst?'uation may take place in early pregnancy. This 
is infrequent, so that a woman who is unwell regularly, however scantily, 
is almost always wrong in her suspicion of pregnancy. When a periodic 
flow does occur during gestation — and a woman calls any more or less 
periodic flow her courses — careful questioning will elicit evidence of 
lessened quantity, a thin or serous character, or some variation in typical 
increase and tapering off. Such flow rarely takes place after the third 
month, when the decidua reflexa and vera have no longer a cavity 
between them. The source lies usually in some lesion of the cervix, in 
an endometritis or polyp, or even in a placenta that is prsevia. A 
patient illegitimately pregnant not infrequently denies amenorrhoea, or 
places the last period later than the true time. The denial may be 
volunteered in the hope that during local treatment a sound will be 
passed. A few cases have been reported wherein menstruation appar- 
ently continued throughout pregnancy, or took place then only. 

c. Pregnancy sometimes begins in patients not menstruating. Concep- 
tion may occur before the function is established, as is de rigueur among 
certain of our Indian tribes; or after the function has ceased; or it may 
take place during the physiological amenorrhoea of lactation; or, lastly, 
in those who are in the habit of skipping periods. It should be said also 
that impregnation happening just before a period may affect it little. 

Nausea and Vomiting. This is a frequent accompaniment of early preg- 
nancy, ranging from an occasional qualm to inability to retain any food. 
It is a reflex from the stretching of the uterine muscle-fibres and nerves 
or from pressure in the pelvis. Occurring late in pregnancy, pressure and 
displacement explain it. Its grades or degrees might be stated clinically 
as follows : (a) Nausea absent or slight in a considerable percentage of 
cases; (b) nausea with occasional vomiting duriug the second and third 
calendar months (fourth to thirteenth weeks) — a very common condition; 
(c) long-continued, distressing, debilitating, but not dangerous, retching 
and vomiting; (d) vomiting imperilling the health, and (e) threatening 
life. The disorder is generally a morning sickness, on first rising, or 
may be only after meals, or solely when the stomach is empty. Infre- 
quently it begins soon after conception, and may last throughout gestation. 

Its value as a witness to pregnancy is scant, since it occurs in gastric 
catarrh, chronic nephritis, and as a reflex in pelvic disorders and many 
others. If it has always appeared at a given time in previous pregnan- 
cies it has some weight. 

9 



[30 PHYSIOLOG V OF rillCONANCY. 

Salivation many times aooompanieg the sickness. The secretion is 
tenaoioufl and difficult of expectoration, hence the name tl spitting cot- 
t * » 1 1 . Heartburn, abnormal appetites. Longing or loathing toward vari- 
ous strange articles of food, toothaches, and the like, may be present. 

Enlargement of the breasts, with throbbing, tingling, Btretching ful- 
ness, or secretion, may be complained of, with tenderness of the nipples, 
and the patient may have noted that her clothes are too tight, but all 
these are matters belonging to the physical exploration. We need only 
mention irritability of the bladder and altered or perverted sensations, 

to dismiss them as of UO moment. 

Quickening is the sensation imparted to the mother by foetal move- 
ments, from the least tremulous flutter to painful somersaults that keep 
her awake with acute pain. The motion is usually perceived midway 
in pregnancy, yet may be felt in pregnancies other than the first as early 
as the third month, or it may never be discovered throughout. Its 
importance lies wholly in the mind of the laity. Movement of gas in 
the bowel counterfeits it, and muscular contractions in the belly wall. 
Or the sensation may live only in the imagination. Cessation of motion 
may be due to death of the foetus, but temporary or even permanent 
stoppage of these feelings on the mother' s part is not incompatible with 
a living child. 

II. Mammary Signs. 

Summary of Signs and Approximate Date. 

1. Increased size ; nodular feel ~| 

1 Veins 

* , '. '. ' ' ' .' " * \ \. ' \ End of 2d month, > 

3. Changes in primary areola ; pigmentation, elevation, 

wrinkling, follicles ........ J 

4. Milk 3d month. 

5. Secondary areola 5th month. 

1 . The Breast Enlargement of pregnancy differs from simple fat deposit 
by the firmness and knotty, uneven character to the touch. This is due 
to increase in size and number of the glandular lobules, swelling of the 
connective tissue, and increased deposit of fat between the lobules. In 
the early months the change is to be distinguished most clearly at the 
edge, but later the strings of nodules or tiny grape-clusters seem to 
extend toward the centre. Still later a certain relaxation in the whole 
breast is seen. The tension may stretch the skin into silvery lines, like 
the striations on the abdomen, and these constitute permanent markings, 
often purplish in color. 

2. The Veins enlarge, forming a blue tracery under the skin or slightly 
elevated above it. They run across the breast and into or around the 
areola. To bring them out fully the centre of the breast may be circled 
with pressure for a moment, preferably in a bright light that strikes the 
surface obliquely. 

3. The Primary Areola. Pigmentation. The darkened base on which 
the nipple stands becomes in women of the brunette type the seat of a pig- 
ment deposit that renders it not unlike the tint of the negro's skin, ranging 
from reddish-brown and brown to black, the depth of color usually de- 
pending on the patient's complexion. In very light blondes there may 

1 In this chapter the word " month " denotes the calendar month. 



DIAGNOSIS OF PREGNANCY. 



131 



be no discoloration, though often, even when pigment is not visible, red- 
dening or a congested look is noticeable — " the delicate rose-color ; ' of 
Montgomery. 



Fig. 130. 



Fig. 131. 




Brunette. Pigmented primary areola ; slight Brunette. Wrinkling of primary areola. Well- 

secondary areola. defined secondary areola, S. A. 



Fig. 132. 



Fig. 133. 




Blonde. Follicles, F. Milk. Faint 
secondary areola. 




Blonde. Elevation (E) of primary areola. Follicles. 
Secondary areola. 



Fig. 134. 




Relaxed breast of multipara. Veins. Secondary areola. 



[32 PHYSIOLOGY OF PMEGWA2WY, 

Eleva i ion of tin' areola is common in fair women. The puffy thick- 
ening and oedema, raising the surface slightly, level or rounded, Like a 
fciny breast on the breast, are readily brought out or accented by gently 
putting the Burrounding skin on the stretch. 

Wrinkling or contractility of the areola is produced by the increase 
in sensibility and Bize of the subareolar muscle. These hand-, mostly 
circular, arc 2 nun.. ,',. inch, in thickness, according to Testut Fric- 
tion or cold or emotion will cause contraction, thereby puckering the 
skin of the areola over them, and throwing the nipple forward. This 
i- in no sense an election, although the phenomenon is commonly called 
ereotility of the nipple. 

MONTGOMERY'S Follicles make up two to twenty small papular 
prominences on the areola, 2-3 mm. high. They are enlarged sebaceous 
follicles, and at times moist, lubricating the nipple. Stretching of the 
skin or action of the muscle of the areola renders them more easily seen. 

4. Milk. Pressure on the breast and a moment's dextrous stroking of 
the ducts running toward and beneath the areola will bring colostrum 
after the third month. There may be branny, dried scales of it on the 
nipple. It is water-like, or slightly opaque, or later, occasionally yellow. 
This is the most important of the mammary signs in the woman preg- 
nant for the first time, but, inasmuch as milk persists in the breast there- 
after, it gives no help in other pregnancies. As a curiosity, it may be 
mentioned that milk has been found in virgins, or has been developed in 
them — or even in the male — by nursing. The primitive man is sup- 
posed to have helped suckle the young, when families were larger. 

5. Secondary Areola. Where the primary areola fades into the skin 
there appears, at the fifth month, a network of pigment around a certain 
number of light spots, each tiny circle having for its centre the opening 
of a follicle. These washed-out spots are rarely absent altogether, usually 
run about the circumference of the dark surface, and may extend all 
over the breast. Next to the milk this is the most valuable of the 
mammary group in the primigravida. 

Value of the Mammary Signs. In first pregnancies, with no history of 
long-continued pelvic disease, the changes enumerated above furnish 
strong presumptive evidence of pregnancy. They are important in 
conjunction with other signs. All the indications are rarely present at 
once in the same case. After the first gestation the signs remain. Vari- 
ous ovarian and uterine disorders, such as tumors, may bring about 
similar appearances. Masturbation frequently does it, in a certain degree, 
even where the nipple is not handled. 

In practice, breast indications help one in the unmarried suspect. A 
girl with amenorrhcea and nausea is not to be lightly subjected to biman- 
ual examination or to a question that may be a grave insult; but, under 
the pretext of investigation of the heart or lungs, the sight of a nipple 
that shows distinctive alterations will warrant further steps. 

Finally, if pregnant, we look to the organ's fitness for function, and 
teach the patient to bring out a stunted, creviced, inverted, or tender 
nipple by massage and traction. 



DIAGNOSIS OF PREGNANCY. 133 

III. Abdominal Signs. 

Summary of Chief Signs and Approximate Date, 
On palpation : 

1. Size of tumor, and typical growth . . From 4th month. 

2. Intermittent contractions 4th month. 

3. Foetal parts -> 

4. Foetal movements }■ 5% months. 

5. Abdominal ballottement J 

On auscultation : 

6. Foetal heart l 

7. Uterine souffle X 4% months. 

Preparation for Examination. With clothing unfastened and opened, 
and all waist-bands loosened, with corsets off and bladder emptied, the 
patient lies down on the office table or on a firm bed or lounge. A 
pillow bends the head somewhat forward on the chest, and the shoulders 
are preferably slightly raised by an inclined plane resembling a bed-rest 
or by a second pillow under the first. This forward curve of the spinal 
column does not extend below the scapula. Such a position, with the 
legs and thighs flexed, relaxes the abdominal walls to their utmost, 
except very late in pregnancy, when a straighter posture is better. A 
sheet covers the legs and trunk ; through this or under this examinations 
may be made in most instances, but one uncovers to listen with the steth- 
oscope or for thoroughness in obscure conditions. 

Warm hands have a more acute sense of touch than cold. Cold con- 
tacts will cause reflex contraction of the muscular walls. Gentle palpa- 
tion may bring out all the facts. The skilful use of some force may 
yet give the impression of light-handedness by gradual increase of press- 
ure. One does not prod with the finger-tips nor play the piano on the 
surface. With the finger edges touching, the facies of the last phalanges 
pass along the uterine walls. This is one kind of touch — the circling, 
sliding contact. The other is a quick push or gentle thrust, to estimate 
the various resistances. The latter gives more information, but is 
resented by a sensitive surface. 

The examination is made in due order : inspection, palpation, auscul- 
tation. 

Inspection. 

Contour. It is said that in the second month the hypogastric region is 
flatter and the umbilicus deeper than normal. Enlargement of the abdo- 
men begins after the third month, as the uterus rises well above the brim 
of the pelvis. Regular increase takes place until two to four weeks 
previous to delivery, when "sinking" or "lightening" occurs, the 
lower pole settling into the pelvis, and the patient experiencing the com- 
fort of easier breathing and looser waist-bands; but, on the other hand, 
disturbed by increased bladder pressure. Typical evidences of settling 
are absent in very many women. 

The protrusion of the belly-wall is not symmetrical, being commonly 
most distinct in the later months to the right of the median line, owing 
to the torsion of the uterus. Fat deposits in the gluteal regions and 
over the hips are noticeable in addition to that in the abdominal wall 
itself. The navel may protrude as the development nears term. 



[34 PHYSIOLOGY OF PREGNANCY. 

Pigmentation and striatum. Along the median Line of the abdomen a 

dark track of brOWD 18 dearly traced from the pubes around the navel 

and an to the ensiform cartilage. It is discolored most in those with 
darker skins, and is one-eighth to one-half inch in width. It is part of 
the pigment dropped in places where capillaries are few, along the front 
foetal closure line, on the lips, abdomen, vulva, and perineum (Ahlfeld). 
The other pigment markings or spots on the face and body are mostly a 
vegetable growth (chromopnytosis). The darkened abdominal line may 
be found in boys, in virgins, in brunettes, and in pelvic disorders. This 
change begins in mid-pregnancy. 

Streak- or stria-, resulting from stretching of the skin, appear on the 
lower abdomen. These " linese albieantes" vary in color from silvery 
white through pink to bluish and faint purplish tints. They are wavy 
and irregular, and in direction commonly lie in concentric zones around 
a centre just below the umbilicus. They belong chiefly* to the last 
trimester. The skin injury is permanent. On the breasts, the thighs, 
and the buttocks the markings are also seen. 

Value of Inspection Signs. Any other cause for abdominal enlargement 
or skin tension will produce like effects; therefore, these things are of 
no import. We enumerate them for completeness in description. 

Palpation. 

The signs brought out by this means are : Size of uterine tumor and 
regular growth, intermittent contractions, foetal parts, foetal movements, 
and abdominal ballottement. 

Size. The fundus may be felt as it begins to rise two or three fingers 
above the symphysis in the fourth month (sixteenth week). At about 
the sixth calendar month (twenty-sixth week) the navel is reached, 
although this landmark varies so greatly in its distance from the pubes 
and ensiform that it constitutes a measure of no great accuracy. The 
ensiform is reached with the maximum height at eight and one-half 
months (thirty-sixth week), while at term the rounded upper limit of 
the uterus is somewhat lower. To find the fundus most readily the 
hand is laid transversely above the expected level, and its ulnar border 
depresses the abdominal wall; this edge works slowly downward until 
the uterus is capped by the bowed hand. 

To be of value the development of the organ must be progressive and 
correspond in a general way to the supposed duration of pregnancy as 
evidenced by other signs. Advance is most rapid in multigravidae, par- 
ticularly where the abdominal muscles are lax, the whole organ standing 
high out of the pelvis; with twins or hydramnion, and in vesicular mole. 
In pertain cases no sinking of the fundus occurs, nor is it found where 
the muscular layers lack tone, or where an obstruction or a placenta 
holds the presenting part up out of the pelvis. The factors affecting 
the height are so various that exact figures possess scant value. 

Incidentally note is taken of pendulousness of the abdomen, excessive 
fat deposit, diastasis of the recti muscles, and tumors in the uterine walls 
or in the neighborhood. 

Fcetal Parts. The characteristic to the touch which differentiates 
this tumor from other smooth, ovoid, or pear-shaped semi-fluctuating 



DIAGNOSIS OF PREGNANCY. 135 

cyst-like growths, is that some parts are harder, some softer; that the 
solid parts are of various sizes; that these surfaces aud knobs can be 
identified as actual parts of a child — more particularly as the limbs and 
head and back. These landmarks may disappear under a general resist- 
ance as the womb-wall contracts, to reappear as the tension passes off. 
Occasionally the face or the feet may be distinctly recognized. 

Foetal parts clearly felt furnish one of the two or three best signs of 
pregnancy. It is most uncommon to find a tumor bearing distinct resem- 
blance in shape to a foetus. In cases of excess of liquor amnii or tender 
or tense uterine walls, one may be unable to outline the child. Foetal 
parts may be detected in the sixth month or a little earlier. 

Foetal Movements. The hand laid quietly on the abdomen detects a 
thrust or push within the womb. Early, it is felt as the gentlest of 
throbs. Later the motion is either general or local; either the entire 
body changes its position by partial rotation, with a rolling, sliding 
motion, or else quick blows are dealt at one or more spots; or, finally, 
a prominence travels along under the lifted skin. To bring out such 
action in a quiescent foetus one may have to gently push or toss the child. 
The motion is most easily developed at one cornu where the feet are 
found. 

This sign, when clearly detected by the examiner, ranks with the last 
in importance. It may be simulated by rumbling of gas in the bowel 
or by localized contractions of the abdominal muscles. These resem- 
blances are said to be occasionally very deceptive, and women themselves 
are not infrequently deceived, but patience should always give the 
medical man certainty. Sometimes the motions are rhythmic. Failure 
to detect movements does not necessarily mean a dead child or negative 
pregnancy. 

The date of detection depends on one's skill, in part. By the time 
the foetus is a foot long the impulse is vigorous enough to feel — that is, 
by the sixth month — often earlier. 

External Ballottement. This is the sensation imparted by a displaceable 
mass floating more or less freely in fluid. A hand on either side of the 
fundus, the operator facing the mother's face, may be able to push an 
irregular bulk to and fro; or the foetal part may be rapidly moved under 
the hand; or, typically (therefore seldom), the fingers may, with a light, 
quick thrust, drive away a ball that bobs back again against their tips. 
This distinctive " dipping" and return, or repercussion, is only felt by 
the route of the abdomen in cases with abundant amnial fluid, or in thin 
persons, in the fifth month, through the fundus. The best demonstration 
of this sign is to be had when the head is in the fundus and is cast to 
and fro as it balances over the shoulders. 

The date of detection of this form of tossing is usually after the uterus 
has risen well into the abdominal cavity — the sixth month. The value 
of the sign is great, and only pedunculated tumors or wandering organs 
like the kidney are likely to simulate it. 

Intermittent Contractions. A rhythmic and painless hardening of the 
uterine walls occurs every five to ten minutes, lasting from one-half to 
five minutes. The contractions may be elicited by friction or by the 
touch of the cold hand. These alterations in tension are noted as soon 
as the fundus is high enough to grasp — that is, from the fourth month; 



136 PHYSIOLOCY OF rilECSASCY. 

luit bv conjoined manipulation are appreciable from the earliest begin- 
nings of pregnancy. 

This sign has a definite value as showing a condition of hypertrophy 

of the muscular wall of the uterus, and because the disorders that like- 
wise develop this reflex are infrequent. A uterus distended by retained 
menstrua] blood (hsematometra), or by a soft uterine fibroid, will act in 

the same manner. A greatly distended bladder will give the same 
sensations. 

In practice the muscular contraction is of service also, because the rigid 
round Ligament gives us knowledge of the seat of the placenta, informa- 
tion especially desired in case of Cesarean section. 

Percussion is infrequently employed because we can map out the gravid 
uterus otherwise. In tense abdomens it serves. It may be stated as 
a rule that after the fifth month the uterus is always in contact with the 
front wall of the trunk-cavity with no intestinal loops intervening. 

Auscultation. 

The ear brings out four evidences of pregnancy: Fcetal heart, uterine 
and umbilical murmurs, and foetal shock. 

Foetal Heart. The sound is generally double, like that of the adult 
apex, and at a rate nearly twice that of the maternal pulse. It has been 
often compared to the muffled tick-tack of a watch under a pillow. A 
clearer notion may be acquired by the student who listens through an 
infant's back. To count it calls for practice on his part, but skill comes 
with persistence and arms him for two important occasions. 

The rate is between 120 and 150, and may be increased by the activity 
of the child and by fever of the mother. The rapidity is greater at the 
beginning of a pain, slowing as the pressure increases (seldom dropping 
below 100), even ceasing momentarily at the acme. Variations of 20 
beats in the same fcetus are frequent. Sex cannot be determined by the 
rate. Boys and larger children were supposed to have slower heart- 
action than girls and smaller children, and the percentage does fall a 
little in their favor, but the Frankenhauser theory, that this is reliable 
or even an approximate index of sex, is discarded. 

The heart is heard most commonly between the navel and the anterior 
superior spine of the ilium on the left side, because the back of the child 
is located there in the usual position, the left-occipito-anterior. If the 
previous palpation has indicated that the back will be found in some 
other place, we listen in that spot, and confirm the diagnosis of position. 
In the flexed foetus the heart is placed as near one extremity as the 
other; it is heard below the navel when the head presents, because the 
head sinks into the pelvic brim. Should the breech present, the focus of 
greatest intensity late in pregnancy will be above the umbilicus or at its 
level. There is some property of the living tissues that prevents the 
heart from being heard over an area larger than 2 to 4 inches, 5 to 10 
cm. A second focus may be detected at the spot where another part 
of the child presses against the wall, or in case of twin pregnancy. 
Faint hearts are heard over a small area. Occasionally a wide diffusion is 
encountered. 

The date at which the heart may be heard is a little after mid-preg- 



DIAGNOSIS OF PREGNANCY. 
Fig. 135. 



137 




Defective method of listening to foetal heart ; the neck is bent, the middle ear congested. Exami- 
nation is here shown on the low cot, as it corresponds to the bed or sofa in private practice. 



Fig. 136. 



] : : j- — : — | 


^^ 


. 


HjH^ KjP 1 g 


r*!&j 






-.«.,.-. 


j^^J 


EjMT^i^fciiBi 






E^B ' mr 







Defective method of listening for the foetal heart by standing and leaning over. The fulness of the 
cerebral vessels caused by this position is indicated in the distended veins on the forehead. 



L38 



PHYSIOLOGY OF PREGNANCY. 



nancy; the time is Bomewhal dependent on the skill of the observer. 
1 1 is -aid t«> be audible in some oases as early as the fifteenth or sixteenth 

Week. 

In value, no BigD compares with this. It IS certain. The chief fallacy 
lies in mistaking for it the aortic pulsation transmitted through the uter- 
ine masSj or arterial pulsation on it.- surface, or the sound of the maternal 
heart. A finger 00 the radial of the mother establishes the connection 
with her heart, <>r the reverse. Moreover, a transmitted maternal cardiac 
impulse grows Btronger in tone as the ear works upward toward her chest. 
Occasionally one finds that he is listening to the pulse in his own ears. 
The only troublesome uncertainty will occur when the mother's heart is 
acting excitedly at about the same rate as that of the child, as after long 

labor or hemorrhage. 

Fig. 137. 





Ja 


1 


mi 


•*H nfoftA 










*HM^ 






m I^B 


• 



Better position for listening to the fcetal heart ; straight neck, easy posture, fingers on radial. The 
assistant presses on the fundus. 



The heart is rendered faint or inaudible by an occipito-posterior posi- 
tion, a very fat abdominal wall, excess of liquor amnii, anterior attach- 
ment of the placenta, by loudness of the uterine souffle, or persistent noise 
of gas in the bowels. Death of the child does away with this sound, of 
course ; but repeated observations of such absence may be necessary for 
positive diagnosis, together with default of movements, lack of tone in 
uterine wall and breasts, and the recessiou of other signs. 

Method of Examination. Prepared as described on page 133, the 
patient is to lie preferably where she is accessible on both sides, as 
on a table or couch. The stethoscope is used for early or difficult 
cases ; but on this yielding surface many observers find that more can 
be accomplished with the ear. It is expedient to train the ear, for 



DIAGNOSIS OF PREGNANCY. 139 

one does not carry a stethoscope in an obstetric bag, and the most im- 
portant facts obtainable from foetal heart-sounds are those gotten in the 
systematic examinations during the progress of the labor, namely, con- 
cerning the danger to the foetus or the need of prompt interference. A 
single unstarched thickness is not a hinderance to auscultation, as a rule. 
If the listener stands and bends over, or if his collar presses against the 
jugular vein, congestion of the inner ear will interfere with fine hearing. 
To hear best, if standing on the left of the patient (or with a better right 
ear), one kneels at the edge of the bed near the patient's shoulder, 
facing toward her feet. The right ear is laid rather firmly against 
the lower abdomen, compressing the fat layers. To auscultate the right 
side one may kneel opposite the hips and reach across the patient at right 
angles, or pass to the other side. A relatively long count is desirable — 
say, thirty seconds — and should gaps occur in the succession of the 
sounds, one counts steadily across them at the same rate. A hand 
placed on the fundus, pressing toward the pelvis, will arch the child's 
back up toward the listener's ear. Patience, and persistence, and favor- 
able conditions are all requisite at times, while a room without a clock 
and away from street and house noises may be necessary. 

Apart from our subject, the foetal heart has great value in the deter- 
mination of presentation and position; of plural pregnancy; in deciding 
whether the foetus is alive or dead; as a danger signal in labor, a rate 
persisting below 100 or near 200 calling for interference to save the 
child. 

Uterine Souffle. A murmur synchronous with the mother's pulse is 
heard along the left side of the uterus. It resembles the bruit in the 
neck of anaemic girls, and the sound is of a quality entirely unlike the 
tap of the foetal heart. If the hand is laid in an arch over the ear and 
its back lightly brushed with the finger-tip, a semblance of this murmur 
may be had. Its source is the blood-rush in the enlarged and tortuous 
uterine vessels; it is usually heard loudest, therefore, along the sides of 
the uterus, and particularly along that side, the left, which is turned 
toward the anterior abdominal wall. Here the stethoscope serves best, 
as the murmur is first hunted for in the sulcus above the middle of 
Poupart's ligament, and from that point upward, with rather firm press- 
ure. The murmur is heard earliest in the middle line. Late in preg- 
nancy it may be found all over the uterus; though often it is entirely 
wanting, or, more commonly, is capricious, appearing and disappearing, 
being strongest during the early part of a contraction. It grows louder 
as pregnancy advances, and is most marked in anaemic women. 

The uterine murmur becomes audible during the fourth month. It 
persists after the delivery of the placenta. It is a valuable sign of an 
enlarging uterus, but lessened in importance as proof of pregnancy by 
its presence with large uterine fibroids, or even in association with 
ovarian cysts or chronic metritis. 

Funic Souffle. The umbilical murmur is synchronous with the foetal 
heart, and heard usually over the child's back. It is produced by ten- 
sion, pressure on and displacement of the cord, originating, as a rule, in 
the umbilical vein (Winckel). In some cases it may originate in the 
heart itself — even in an endocarditis (Bumm). The sound is heard 
more frequently when the cord is coiled about the foetus, when the cord 



140 PHY8I0L0QY OF PREGNANCY. 

is abnormally slum or Long, or when it is deformed — e. o*., when the 
insertion la velamentous. Hence, this bruit furnishes an index of a 
certain amount of danger to tin* child, according to Winckel. It is 
heard after mid-pregnancy, but is relatively rare in the writer's expe- 
rience. 
Foetal Shock. In listening with the stethoscope as early as the third 

Or fourth month (fourteenth to sixteenth week) the trained ear may some- 
time- get the tiny thud, with the sound that accompanies it, produced by 
foetal impact. The tap of the linger on the hack of the hand held near, 
hut not in contact with, the ear, is not unlike it. Winckel says it occurs 
in 10 to 15 per cent, of all cases. Gas moving distantly in the bowel 
somewhat resembles it. 

IV. Pelvic Signs. 

By vaginal and abdomi no- vaginal examination the chief indications of 
pregnancy are : Purplish hue; softened cervix; compressible isthmus; 
bulging, elastic corpus, and vagiual ballottemeut. Foetal parts may also 
be detected. 

Method of Examination. The details concerning loosened clothing, 
coverings, and the dorsal posture, with elevated head aud shoulders, have 
been given on page 133. Just before lying down the patient is requested 
to urinate. When an early diagnosis is urgently desired, and the rectum 
is loaded, an enema may be given; or if the bowels are much distended 
with gas a second examination is asked for, and a three-day diet, mostly 
of meat, fish, eggs, and milk, is ordered, together with a laxative, and, 
perhaps, a tablet containing charcoal, pancreatin, bismuth, and ginger. 
To lift the small intestine out of the pelvis aud secure access to the rear 
of the uterus, particularly in retropositions, the injection of air into the 
rectum with the patient in the knee-chest or latero-prone posture is 
worthy of trial (Kelly). Nitrous oxide or chloroform are final resorts. 
By all these means tension is lessened and the reach down into the 
pelvis facilitated without some of the harsh methods originally counselled 
by Hegar. 

In order to put the muscles of the pelvic floor and those of the abdom- 
inal wall, as well as the adductors, at a disadvantage, the patient is 
brought down to within a foot of the near edge of the table, the feet 
placed eight or ten inches apart, and the knees spread abroad to their 
utmost. If a bed is used it should be firm, that the buttocks may not 
sink into it. The patient lies at a right angle with its length. Five min- 
utes' scrubbing of the hands should be a routine preliminary to vaginal 
examination, because of the special susceptibility of the gravid woman 
to infection, because the finger may need to explore w T ithin the cervix, 
and because, if premature interruption of the pregnancy should soon 
occur one might have infected his patient. The vulva is cleansed. One 
passes the finger in by sight in order to make no unnecessary contacts, 
especially with an imperfectly cleansed anal region; the left hand draws 
the labia wide apart so that the first contact of the examining finger or 
fingers will be with the hymen or the vaginal wall inside it. Here 
again, by gentle firmness, a long reach is practicable, the web between 
the fingers carrying the perineal body far backward and inward. 



DIAGNOSIS OF PREGNANCY. 141 

If possible, the uterus is gently and quickly caught between the two 
hands and examined. If out of easy bimanual reach, the finger tips 
are slipped beyond the cervix and hooked forward, lifting the uterus 
bodily toward the anterior abdominal wall through the intervening intes- 
tinal coils. The outer hand depresses the hypogastrium to reach low 
down on the back of the uterus, or gently makes circling massage move- 
ments with gradually increasing pressure as the muscles yield. The 
patient is told to cough or breathe deeply, or her attention is side-tracked 
by a question. In these ways, quickly tried, the hands, one on each face 
of the uterus, reach as far toward the cervix as may be. Beginning at 
the cylindrical neck, the anterior and posterior surfaces are examined 
from cervix to fundus, for compressibility just above the cervix, next for 
bulging of the walls of the body, following the profile and estimating any 
increase in thickness of it, determining at the same moment its consist- 
ency, whether resiliency is present or not, and, lastly, swinging the body 
from side to side over the stationary inner fingers to appreciate breadth 
and the denser spot. The cervix should be palpated at first no more 
than is necessary in order to identify it, for manipulation here quickly 
induces intermittent contractions, whereby the organ hardens and some 
of the signs disappear. As an alternative, the uterus may be toppled 
over backward and the thinned isthmus brought between the fingers of 
the two hands. 

Whenever the fundus lies in the sacral hollow and cannot be swung 
forward, a tenaculum hooked into the cervix will draw down the uterus 
within reach of vagi no-abdominal or recto-abdominal palpation. 

Inspection of the cervix for color-changes, with the speculum, is next 
in order. A subsequent miscarriage may be attributed to the physician's 
" instruments" when there is no connection whatever. With certain 
patients one avoids the chance of any examination but the manual, 
which can do no harm except in women who abort on the slightest of 
provocations. 

Rectal examination gives little information in normal cases, but is 
necessary in uterine or ovarian displacement, or to outline and differen- 
tiate tumors, exudates, or hemorrhages. 

Purplish Hue of the Vagina. Venous congestion from hypertrophy of 
the vessels runs up the entire vagina. On drawing the vulva open the 
dusky discoloration is seen readily on the anterior vaginal wall below the 
urinary meatus. A faint venous color may show itself by the end of 
the first month. Chadwick showed that 80 per cent, of pregnant women 
developed the color by the end of the third month. The fallacy is that 
heart disease, varicose enlargement, and the like may produce analogous 
coloring. Late in pregnancy the pudenda are relaxed, soft, and swollen, 
while moistened by free secretion of mucus. 

Purplish Hue of the Cervix. "A more or less marked lividity of the 
vaginal portion of the cervix may be observed almost from the first 
month after conception. The purplish color of the cervix is not only 
developed earlier, but is more constantly present than that of the vagina" 
(Jewett). 

Enlarged arteries are felt pulsating in the vagina, often suggestive of 
foetal movements or ballottement. 

Early Changes in the Uterus. Bulging out of the corpus; elasticity or 



l 12 



PHYSIOLOCY OF rilECiyAXCY. 



doughiness of the corpus; compressibility of the isthmus I I [egar'e sign : 
softening of the cervix; regular growth. 1 

All these may be said to belong to the sixth week. They are here 
listed in the order in which they are mosl frequently noted. 



Fig. 188. 



resilient 




cotxtracnoPi 



Changes in the pregnant uterus of the sixth week, on the left when relaxed, on the right when 

contracting. 

Bulging Out or Bellying of the Body of the Uterus. Con- 
sidered in profile the anterior surface of the virgin uterus may be said 
to be approximately flat or slightly arched, whereas the posterior face 
shows a convexity. During the intermittent contractions that are appre- 
ciable by careful palpation in most uteri, in the unimpregnated condition a 
more globular form and a hardening of the whole uterine body may be 
detected, the antero-posterior diameters especially increasing. From the 
fourth or sixth week of gestation this alteration is pronounced, and is 
more commonly present than any other, attracting attention by the over- 
hanging or forward projection of the anterior wall of the body. At 
times it feels like a rounded transverse ledge or cornice, and may be 
found in front, behind, laterally, or in all directions at once. During 
relaxation this shape is not present, but springs into evidence when 
contraction comes on. 

Elasticity, Doughiness, or Softness of the Body of the 
Uterus. If the empty uterus were always as bard as a raw potato, and 
the body of the gravid uterus elastic as a rubber ball, the diagnosis were 
easy. Unhappily the conditions are not quite so simple. The corpus 
uteri, when of typical consistence to the touch, is resilient, distinctly 
suggesting u the fluid elasticity of the growing ovum" within. But in 
the absence of contraction the body may be soft, giving the impression 
that one could feel the opposing fingers through its substance — though 
rarely is this marked. Or it may be doughy in consistence, giving to 
the finger the impression of pitting or bogginess. Finally, the harden- 
ing of the whole muscular wall may make of the corpus a very firm 

1 The denser spot and the furrowing or folds on the uterine wall are findings, by the writer, belong- 
ing to the period from the sixth or eighth week up to the sixteenth or twentieth. The first gives a 
sensation to the finger as though an almond lay in the cavity— usually near one of the cornua— prob- 
ably a localized contraction around the ovum, while the rest of the corpus is relaxed. The groove 
or grooves, with or without a ridge, run up and down oftener than across, aud sometimes give the 
impression of a heart-shaped organ or one divided into chambers. 



DIAGNOSIS OF PREGNANCY. 



143 



globe without elasticity. The change from one of these conditions to 
the other may take place under the finger, and such variations are notable 
and important. 

Compressibility of the Lower Uterine Segment. Just above 
the cervix and between it and the rounded body above there is a strikiug 



Fig. 139. 



Furrow 




Right and left halves of frozen section of uterus at 2% months, showing thin, relaxed walls and 

thick decidua. (Pin arc.) 

absence of resistance, the fingers of the two hands coming together closely. 
The thickness is no more than that of a visiting card, when the sign is 
fully developed. Often the yielding sensation is partial, yet unmistaka- 
ble. It is accounted for by reference to the section of Pinard's uterus 

Fig. 140. 




Bimanual examination for compressibility of the isthmus at the sixth week. 

(Fig. 1 39) (imagining the bulk of this ovum as somewhat less), for the 
enormously thickened mucosa contains many dilated and irregular blood 
sinuses which reach their maximum development at the end of the second 
month, and the decidua is very pulpy and soft. 

Well-defined compressibility was found by the writer in two-thirds of 
a series of fifty cases. The editor of this system taught him this sign 



[44 PHYSIOLOGY OF PREGNANCY. 

long before Segar'e assistants published it. Of all the bimanual signs 
of early pregnancy it i- tin- most important. 

Size. The increase is very regular, and may be determined by com- 
parison of findings three week- apart. Unhappily the linger has not a 
memory of thai duration. Increase in Length up to the sixth or even 

the eighth week is very difficult to estimate. But with the increase in 
thickness it Is different, since the antero-posterior dimension of the cor- 
pus is readily palpated, and expansion is appreciable at the sixth or 
eighth week, as the body then measures two inches, 5 em., from front to 
hack. At the end of the third month the organ is 5 inches, 12.5 em., 
in Length, 4 inches wide, 11 em., and 3 inehes thick, 8 cm.; that is, 
about the Bize of a man's list lightly closed. 

The Date of Appearance of the signs that are determined by 
conjoined manipulation is the sixtti week, on an average ; but practice 
enables one to find them in favorable cases as early as the third or 
fourth. At the eighth week they ought to be distinct. Later the ovum 
fills the cavity more and more completely, and the compressibility is 
lost after the third month. 

Fallacies connected with the early signs are these: (a) Vacillations 
in consistency (intermittent contractions) take place in the non-gravid 
uterus, but the range is a short one, elasticity and well-marked boggi- 
ness of the body being infrequent, with no marked thinning at the lower 
uterine segment. (6) Anteflexion with atrophy of the junction of cervix 
and body will yield the hour-glass isthmus with a body rounding out above 
the thinned angle. Here the smallness of the body and its density must 
exclude pregnancy, with the lack of increase in size or elasticity proven 
by an examination two or three weeks later, (c) Hyperemia, hyperplasia, 
or subinvolution will exhibit an enlarged body, but the history and symp- 
toms of chronic uterine disease, the resistance to the touch, and the 
absence of Hegar's sign, together with the stationary character of the 
findings, will exclude pregnancy, (cl) Retroversion with flexion will 
present swollen conditions resembling the alterations of pregnancy. 
Reposition — and consequent shrinkage — may be necessary before the 
diagnosis can be settled, (e) A soft submucous fibroid causes hemor- 
rhage rather than ameuorrhoea. 

Softening of the Cervix. After the first month the consistency of 
the cervix changes. First a velvety feel like that of the mucous lining 
of the cheek is noted, covering the hard knob beneath. The softening 
progresses upward rather slowly until the sixth month. At the eighth 
month the whole cervix has become yielding, so that the finger passes 
through the canal without resistance. Indeed, at term there seems to be 
no projection, the cervix having the same consistency as the vaginal wall. 

" A similar softening occurring from pathological causes lacks the same 
progressive character." Conversely, a hard cervix and especially a 
small firm cervix rules out a supposed late pregnancy, and thus, in the 
differential diagnosis of obscure abdominal tumors, becomes a factor of 
no mean value. 

Internal Ballottement. One or two fingers against the anterior vaginal 
wall close to the cervix give a sudden impulse to that part of the foetus 
resting against the anterior uterine wall. The child floats up through 
the liquor amnii, and after a slight and momentary excursion settles back 



DIAGNOSIS OF PREGNANCY. 



145 



against the finger-tips, repercussing with a very gentle tap. The depart- 
ure alone, without evident return, is enough to constitute this sign. In 
order to develop it the long axis of the uterus should be vertical, and 
this is brought about by a posture half-way between sitting and lying 
down on the edge of a bed or table. 

The value of the sign is very great, but there are others that develop 
much earlier that are of greater import. It is detected when the child 
is large enough to impart sensation to the finger, and ceases when the 
bulk of the foetus too nearly fills the cavity, being present, then, during 
the fifth and sixth months (twenty-one to twenty-six weeks). The foetus 
is too light before this time, and there is too little fluid later. Bal- 
lottement is absent with scanty liquor amnii, with twins, and with the 
placenta low in front. 

The possible but infrequent fallacies in ballottement are an anteflexed 
uterus, a pedunculated cyst or fibroid, internal projections of large cysts, 
vesical calculus with the bladder full, a kidney floating low, pulsation 
of the uterine artery (Jewett). 



Fig. 141. 




Internal ballottement, semi-recumbent posture, at sixth month. 

Foetal parts may be felt through the vaginal and uterine walls by 
the twentieth week (fifth month, or earlier); the head or breech made 
out by the twenty-eighth week (six and one-half calendar months), and 
reached directly through the cervix during the seventh month (Winckel). 



10 



14(3 



PHYSIOLOGY OF PREGNANCY. 



•s sS 
3 2 



37 

3S 

— 10 
39 

40 i 



3 



r> 



<s 



<•> 



PREGNAXCT Till: SIGNS J5Y MONTHS. 



jS ^^ History. Mammary. 



Suppression 
of menses 
(throughout). 



Nausea. 



Size— nodules. 
Veins. 
Primary areola. 

pigment, follicles, 
corrugation. 



Abdominal. Pelvic 



Nausea. 



Nausea passes. 



Quickening 

(4% months). 



All, throughout 
pregnancy. 

Milk. 



Secondary 
areola. 



All, throughout. 



Uterine body 
bulging,— elastic 
or doughy ; 
isthmus 
compressible ; 
cervix softening. 



As before. 



Purplish hue. 



Fundus rises. 



Fcetal shock. 



Pigmentation. 
Intermittent 

contractions. 
Fcetal heart. 
Uterine souffle. 
Funic souffle. 
Fcetal shock. 



Cervix softens 
progressively. 
Compressibility lost. 
(Fcetal movements.) 



Internal 
ballottement. 



Fcetal move- 
ments. 

External 
ballottement. 

Fundus at navel. 
Striae. 



Internal 
ballottement. 



All, throughout. 



Ballottement lost. 
Cervix patulous, 
pulpy. 



DIAGNOSIS OF PREGNANCY, 147 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 

In the early months 

Anteflexion of the uterus with atrophy of the angle and hyperemia of 
the body may closely counterfeit the organ two mouths pregnant. The 
peculiar elasticity of the corpus uteri and its ready variations from relax- 
ation to firm contraction are missing, while the persistence of menstrua- 
tion, even though scanty, as well as the stationary character of the 
findings, as shown at a later examination, will make the distinction. 

A pedunculated fibroid of the anterior uterine wall is solid, and, there- 
fore, unlike the corpus of pregnancy in consistency. 

An ovarian cyst or a distended tube in the cul-de-sac may suggest retro- 
version of a gravid uterus, especially if moving with the cervix. Their 
tension and clear elasticity are stable, and more marked than those of 
the ovum-filled corpus. 

Chronic metritis and subinvolution, on the other hand, impart to the 
finger a firmer resistance, and not a globular shape nor bellying in the 
antero-posterior diameter, nor do they show Hegar's sign. 

In retroflexion the swollen uterus may resemble the gravid organ of 
the fifth or sixth week, and not until after reposition and shrinkage may 
the difference be apparent. 

The diagnosis of tubal gestation is fully treated of in the chapter on 
Ectopic Gestation. 

In all these conditions experience, expertness, and access to all parts 
of the pelvis in order to map out the organs may, possibly, be necessary 
for a diagnosis. A dubious history, and sensitiveness, and resistance 
may call for repeated examinations or for anaesthesia. One mistake in 
five, or many blanks, are conclusions to be expected. 

In the later months : 

General Rale in Differentiating. Three discrepancies are always to be 
borne in mind as pointing to conditions other than pregnancy: 

1. The rate of enlargement differs from that of the pregnant uterus. 

2. The size and the period of amenorrhoea do not correspond with 
each other. 

3. The most important signs of pregnancy are absent, namely, foetal 
heart, foetal movements, distinctive foetal parts, and the external and 
internal ballottement. Menstruation usually persists. With each of 
the following disorders it will not, therefore, be necessary to reiterate the 
above statements. 

Fat. The general rotundity of the patient arouses suspicion, while 
locally the thickness of the deposit may be estimated by lifting a fold or 
seizing the bulk of the belly-wall between the hands. The whole sur- 
face is faintly resonant on percussion. A bdomi no- vaginal exploration 
fails to bring an organ between the two hands, through which any thrust 
may be transmitted, and the small, hard cervix gives a clue to the size 
of the uterus. Obesity is a frequent cause of amenorrhoea or scanty 
flow, and especially when anaemia coexists. 

Tympanites. Here the girth is variable from time to time, the reso- 
nance is general and obvious, and a firm tumor is lacking. With steady 
pressure while the patient coughs or breathes deeply, a deeper and deeper 



[48 PH78I0L007 OF PREGNANCY, 

reach Binks the hand toward the spinal column. Again, the cervix has 
oof Boftened to tally with the bigness of the abdomen. 

.1n.v7-.s-. The shape i- suggestive, being not prominent, hut rather flat 
in front and bulging <>n the sides, as the patient Lies. Percussion brings 
out tympany in front and flatness or dulness at the flanks, the Level of 
the flatness changing with changes of posture. In pregnancy it is a 
curiosity to find any intestinal coils in front of the uterus when the fun- 
dus has once risen well out of the pelvis. Suppression of the menses is 
often -een in dropsy, and the history of disease of tin; heart, kidney, or 
liver will indicate the cause. 

Ovarian OysU In its earlier stages the resistance is most marked at 
one side of the median line; later it may be central, but this will he after 
long growth; a monocyst is more smooth, globular, and elastic than the 
uterus, and fluctuates all over. The most important point lies in the 
characteristic cyst-sensation imparted to the hands. The uterus, and with 
it the cervix, is displaced toward the back, side, or to the front, as a 
finger, following upward from the small, firm external os may be able to 
ascertain, though the distinction is often most difficult. In the presence 
of a moderately long pedicle there may be a space between uterus and 
cyst into which the fingers can press. The gravid organ of the fourth 
month, rotund, firm, without movements, foetal parts, or heart-sounds, 
and with the cervix far back, where it cannot easily be traced as a con- 
nection of the mass above, most nearly resembles a cyst which has 
crowded the womb backward. But the cervix of pregnancy at this stage 
is boggy on its surface, is usually to be found in the median line, and 
may be followed up laterally into the body. This body and its changes 
in consistence are to be studied, the round ligaments located, if possible, 
and notes made for comparison three or four weeks later. The tension 
of hydramnion is suggestive of a cyst. Cyst and gestation may exist 
together and render the diagnosis difficult. Amenorrhea is not often 
present in ovarian growths, and the patient has commonly a history of 
increasing dysmenorrhea. 

Fibroid Tumors. Most growths of this kind are very hard. Some are 
nodular, and occasionally one bears a likeness to foetal parts. Careful 
palpation and bimanual examination must map out the relation between 
the unsoftened cervix and the tumor or tumors in or on the uterus above. 
A study of the location of the round ligaments may demonstrate the 
common asymmetry of enlargement due to fibromata, as compared with 
the usual symmetry of pregnancy. Instead of cessation of menstruation, 
uterine hemorrhage is the rule, either periodic or continuous, and if 
anaemia stops the flow, the arrest is gradual and not sudden. Occasion- 
ally the new growth is subperitoneal and pedunculated, or the cervix 
may be gaping to give exit to a submucous fibroid. When fibromata and 
pregnancy coexist the tumors grow rapidly, particularly the intramural 
variety, and the combination adds to the difficulty of the diagnosis. 
Unless the tumor is very large and low, the purplish hue of the vagina 
and cervix is not developed in these growths as in pregnancy. In diffi- 
cult cases, again, the final appeal is to time or to chloroform. 

Enlarged Organs. These develop from above downward. The dul- 
ness, the line of the lower edge, and the resonant strip below serve to 
indicate the source of the abdomen's prominence. Encysted dropsy is 



DIAGNOSIS OF PREGNANCY. 149 

rare. Wandering organs, like the kidney and spleen, can be pushed 
upward. Malignant omental and mesenteric growths are lumpy and 
fixed, presenting, if large, a marked cachexia late in life. 

An over-distended bladder gives a history of short duration, pain, and 
dribbling. Retroversion, with or without pregnancy, is often its asso- 
ciate. The catheter settles the diagnosis. 

Phantom Tumor. In spurious pregnancy breast changes, the size of 
the abdomen enlarged with gas and fat, and the imaginary movements 
have led hysterical and anaemic individuals and women near the meno- 
pause or excessively anxious for children into curious errors. The uterus 
is found to be small, and chloroform may be needed to assure the family 
of the self-deception. 

Hcematometra. A growth characterized by monthly increase in size, 
accompanied with severe pains and contractions before the appearance 
of menstruation at puberty, points to an atresia somewhere between the 
hymen and cervix. It is very rare. More rarely still the canal may 
have closed up from injury or disease. 



CHAPTER V. 

DURATION OF PREGNANCY.— EVIDENCE OF PREVIOUS 
PREGNANCY. 

The Duration of Pregnancy. 

No definite statement can be made of the typical normal length of 
the period of gestation. Variations in the apparent duration of preg- 
nancy occur in animals, in which calculations have been made from the 
date of a single coitus. When impregnation occurs in the human 
fen Kile after a single coitus, the date of which has been accurately 
known, as in single women, or in married women whose husbands have 
been absent for months, the average period between the fruitful congress 
and labor is two hundred and seventy-three days. But calculations can 
rarely be based on a single coitus. Even when it is possible to compute 
from one coitus, the period intervening between the fruitful coitus and 
labor varies in different women, and in the same woman in different 
pregnancies. This is explained by several possible causes. The inter- 
val between insemination and fertilization is not constant. We have no 
exact knowledge of the length of time during which the respective 
sexual elements, the ova and the spermatozoa, may retain their vitality 
in the maternal passages. From the data at present known, it is 
assumed that the time of fecundation may vary from a few days to a 
week or more after insemination. Again, gestation may be prolonged 
beyond the usual normal period, or may fall short of it. The precise 
duration of pregnancy cannot, therefore, be definitely determined. 

Should impregnation occur within the first few days following the men- 
strual period, the catamenial flow is almost certain to be absent at the 
next menstrual date; when impregnation takes place shortly before an 
expected period, a partial menstruation may follow at the menstrual 
epoch, but more or less atypical in character. The probable date of 
labor as computed from the last menses becomes still more uncertain in 
women whose history is one of menstrual irregularity. 

Whether or not a woman can give birth to a child ten months or more 
after the last coitus is a medico-legal question ou which the obstetrician 
may be called upon to testify. The French law recognizes the legitimacy 
of the offspring when the apparent term of gestation is within 300 days. 
In Austria the recognized duration of pregnancy is from 240 to 307 
days. In England and the United States there are no legal limits, but 
the possible protraction of gestation is admitted by all legal authority. 
Taylor and Beck, in their works on Medical Jurisprudence, cite numerous 
instances of protracted gestation. Several cases are recorded by obstet- 
ric writers in which pregnancy was believed to have continued 319, 
324, 332, and 336 days respectively after the last menstruation. Dewees 
cites a case which continued for ten calendar months. Playfair, Lusk, 
and Leishman have all mentioned instances of considerable prolongation. 
(150) 



D UBA TION OF PREGNA NCY. 151 

Most frequently in such instances the child is a male and of large size. 
Some women appear always to exceed the usual limits of pregnancy. 

Prediction of the Date of Labor. 

(a) Naegele's Rule for the prediction of the date of labor is based 
upon the fact that the average interval between the beginning of the last 
menstruation and the occurrence of labor is two hundred and eighty 
days. It consists in counting forward nine calendar months from the 
beginning of the last menstruation and adding seven days. This is a 
ready method of computing approximately two hundred and eighty days 
from the beginning of the last menstrual period. The same result is 
gained by counting backward three months and then adding seven days. 
The prediction is usually accurate within a week. An error of two or 
three weeks, however, is possible, since in exceptional instances preg- 
nancy may begin at any period between the menstrual epochs. 

(b) Reckoning from the Date of Quickening. It is a common popular 
custom to estimate the date of parturition from the time of quick- 
ening. But, as the period of quickening varies from the twelfth to 
the twentieth week, and the observations of the patient are always 
liable to error, the method is obviously unreliable. When, however, 
accurate menstrual data are not available, or when pregnancy has 
occurred in the absence or temporary suspension of the menstrual func- 
tion, reckoning from the period of quickening may serve for an approxi- 
mate estimate. 

(c) Mensuration of the Uterus is not wholly reliable for this purpose, 
since the amount of liquor amnii varies in different cases, and the 
size of the foetus is not always the same in different instances for the 
same period of gestation. Moreover, more than one foetus may be 
present. The situation of the fundus cannot be depended upon for 
determining the stage of gestation, for the reasons just stated under men- 
suration of the uterus. The height of the fundus, too, is influenced by 
the tonicity of the abdominal walls, by the capacity of the pelvis, and 
by the direction of the uterine axis. Again, in comparing the situation 
of the fundus with that of the umbilicus, it must be remembered that 
the umbilicus is not altogether a fixed point. 

After eight and one-half months, if the cervix has undergone marked 
shortening, labor is close at hand. Delivery may be expected within a 
few days after the cervix has become greatly shortened. 

(e) Mensuration of the Foetus. The length of the foetus is about double 
that of the foetal ovoid. The length of the foetal ellipsoid may be 
measured with approximate accuracy through the abdominal wall, by 
placing the poles of a pelvimeter on the abdominal wall, one opposite 
each extremity of the foetal ovoid. The measurement may be taken 
more accurately by placing one pole of the pelvimeter on the abdomen 
over the upper extremity of the foetal mass and passing the other pole 
through the cervix and holding it against the presenting part; but this 
method is obviously objectionable and should be reserved for emergencies. 
The rate of foetal development, however, is not uniform. Nevertheless, 
measurements of the foetus, including the diameters of the head, afford 
fairly reliable data for predicting the date of labor. 



152 PHYSIOLO(, Y OF PRFOSANCY. 

The approximate lengths of the foetllfl in the last four months of intra- 
uterine development respectively are stated in tin* following table : 

Lengtb of the F(ETU8. 

Sixth calendar month, 30 to 35 cm., about \2 to 11 inches. 

Seventh calendar month, 35 to 10 cm., about II to 16 inches. 
Eighth calendar month, 40 to 45 cm., about lb' to 18 inches. 

Ninth calendar month, 45 to 50 cm., about 18 to 20 inches. 

Evidence of Previous Pregnancy. 

Evidence of a previous pregnancy which had occurred at any remote 
period, and which had continued but a few months is difficult or impos- 
sible of recognition. Within a few days following the expulsion of its 
contents, the uterus will be found more or less enlarged and the cervix 
more than normally open. It may be difficult of distinction, however, 
from an enlarged and menstruating uterus. Soon after an abortion rem- 
nants of the foetid structures may be looked for — microscopically — in the 
products of a curettage or in the lochial discharge. 

The physical evidences of a previous pregnancy are much more dis- 
tinctly marked after recent parturition at or near term. The fundus 
uteri will then be found in the hypogastric region, much enlarged, and 
the cervix will be patulous. For several days after labor the genital 
discharge corresponds in quantity and character to the lochial flow. 
Fresh lacerations of the cervix may be detected. The vaginal portion 
of the cervix is more nearly cylindrical in the parous than in the nullip- 
arous woman, and its lower border is more or less deeply notched. 
Relaxation of the vagina persists for some time after delivery. The 
fourchette is usually, and the hymen is always, destroyed in the first 
labor. 

The abdominal walls are soft and relaxed, with the skin thrown into 
folds, and its lower half is marked with white, shining lines (linece albi- 
cantes). 

The breasts are tumid and contain lacteal secretion. The presence 
of colostrum corpuscles in the breast secretion indicates a recent delivery. 
The characteristic areolae of pregnancy are in great degree permanent, 
and they afford, therefore, no diagnostic evidence. On the faces of preg- 
nant women frequently there may be seen the chloasma uterinum, which 
sometimes lasts years after parturition. Menstrual and uterine disor- 
ders, however, may cause the same skin affection in women who have 
never been pregnant. 

The general appearance of the woman, even after recent delivery, 
usually presents nothing characteristic. 

After death the recognition of the parous condition is not difficult. 
The cervical canal has lost its fusiform shape; the uterus is enlarged 
and heavier; the corporeal cavity is approximately oval, the inner sur- 
face of the fundus uteri being no longer convex, as in nulliparae, but flat 
or even concave. 



CHAPTER VI. 

HYGIENE AND MANAGEMENT OF PREGNANCY. 

It is the duty of the practitioner of medicine engaged to attend a 
woman in confinement to give her such hygienic instruction as she may 
require and to extend a certain degree of professional attention through- 
out pregnancy. Many disorders and complications are likely to arise 
during gestation, and the woman's welfare may depend in no small 
degree upon the watchful care of her medical adviser. 

Diet. Early in pregnancy some degree of digestive disturbance and loss 
of appetite is the rule. By the fourth month the gastric irritability usually 
begins to abate and appetite and digestion improve. In the regulation of 
diet reasonable regard should be had for the preferences of the patient. In 
this way the morning sickness may sometimes be satisfactorily managed. 
Most foods, animal and vegetable, which are nutritious and easily diges- 
tible, are suitable. In short, the diet during pregnancy should be plain, 
simple, digestible, highly nutritious, and be taken at regular intervals. 
No invariable rule can be laid down for all cases, as the same foods do 
not agree equally well with all patients. Individual fancies, dislikes, 
or indiosyncrasies must be consulted. A sufficiently liberal diet con- 
tributes to improved haematosis, increases functional activity, augments 
body-weight, gives a healthy tone to the bloodvessels and tissues, and 
diminishes the susceptibility of the nervous system to pain and to reflex 
irritation. A suitable diet, too, during pregnancy is obviously essential 
to the normal development of the foetus in utero. In the later weeks 
of pregnancy, when the gravid uterus exercises pressure upon the 
stomach, food should be taken in smaller quantities. 

Exercise. Moderate muscular exertion, as a rule, is well borne. Daily 
walks in the open air are useful both for exercise and recreation. Most 
other forms of light and agreeable exercise are beneficial. Cycling may 
usually be permitted, if practised in moderation and with care to guard 
against accident. Passive exercise will be found highly salutary to those 
who cannot bear the more active forms. Carriage riding affords the neces- 
sary fresh air and sunlight. Horseback riding, carriage riding over rough 
roads, heavy lifting, and all violent muscular strain and overwork must 
be prohibited. Crowded and ill-ventilated rooms should be shunned. 

Properly regulated physical exercise is not only essential to the 
normal progress of gestation, but it doubtless conduces to easy labor. 
It is especially important in women of delicate health and feeble mus- 
cular development. 

Rest. The pregnant woman requires an abundance of sleep. Eight 
hours daily of undisturbed sleep are essential. A n hour or two immedi- 
ately preceding the noon meal may well be added to the usual night's 
rest. 

Clothing. The clothing should be so adjusted as not to exercise 

(153) 



l."» 1 PHYSIOLOGY OF PREGNANCY. 

undue pressure upon the chest and abdomen. Corsets must be pro- 
Boribed. Garments Buspended arouud the waist should be as light as is 

consistent with comfort and health. The heavier clothing should hang 

from the shoulders. Pressure upon the abdomen impeding the ex- 
pansion of the growing uterus and it- contents, favors the develop- 
ment of a not uncommon complication of pregnancy — albuminuria and 

Uraemia, In multipara 1 with lax abdominal walls, relief is often afforded 
by supporting the lower abdomen with a properly constructed supporter. 

Such an appliance must be adjusted with care not to increase the 
pressure upon the pelvic and renal veins. It should exert a lifting 
rather than a constricting pressure. 

Bathing. The functions of the skin should be kept active by fre- 
quent bathing during the entire course of pregnancy, and particularly 
in the later months, when it is important to relieve the kidneys as much 
a- possible of the extra work thrown upon them. Daily baths are advo- 
cated, at a temperature suitable to the time of year and the habits of the 
individual, although it is, perhaps, preferable that the bath be warm at 
first, and rapidly cooled at the finish. To secure proper reaction the 
skin should be rubbed briskly with a coarse towel. 

Breasts and Nipples. Attention should be given to the breasts and 
nipples preparatory to lactation and nursing. If they are retracted the 
patient should be taught to draw them out gently with the thumb 
and finger, for a few minutes daily, particularly during the last few- 
months of pregnancy. This not only serves to develop them, but it 
accustoms them to manipulation and lessens the danger of injury by 
nursing. Strict cleanliness is essential. Daily ablutions with cold water 
are recommended as a prophylactic against fissures during nursing. 
Daily inunctions with fresh cacao butter are better than the astringent 
lotions commonly employed. 

Hygiene of the Pelvic Organs. Vaginal injections are not necessary, 
except in the presence of a leucorrhceal discharge. If injections are 
required a saturated solution of boric acid, one or two quarts, may be 
given with a fountain syringe and with the least possible mechanical 
violence. The temperature should be that of the body. 

Local treatment to a diseased vagina, cervix, and canal may, with 
proper precautions, be carried out during pregnancy. Pregnancy always 
aggravates an existing chronic cervical endometritis; it increases the 
cervical catarrh, the granular degeneration, the secondary vaginitis, and 
vulvar pruritus. The gentle use of warm vaginal injections and topical 
applications of mild astringents and emollients, and, in rare cases, of 
solutions of silver nitrate, may not only improve the local condition, 
but also aid in controlling reflex disturbances, such as nausea and 
vomiting. 

Sexual Intercourse must be restricted; it is usually injurious to preg- 
nant women. Total abstention should be enjoined at the menstrual dates, 
and especially in women who have previously aborted. It is most likely to 
be harmful in the early months of pregnancy and again toward the close. 

The usual marital relations are distasteful to most women at this time, 
and to many are the source of much pelvic discomfort, as well as a promi- 
neut factor in aggravating the nausea of pregnancy and in the induction 
of abortion. 



HYGIENE AND MANAGEMENT OF PREGNANCY. 155 

Digestive Organs. Usually some attention must be directed to the 
stomach disturbances. Allusion has already been made to their dietetic 
management, which is often more efficacious than medicinal treatment. 
In feeble digestion good results may be expected from the temporary 
use of koumyss or predigested foods. When the stomach rejects all 
food resort must be had to rectal alimentation. 

It is important that the bowels be evacuated at least once daily. 
Most women are habitually constipated, and pregnancy commonly aggra- 
vates the disorder and intensifies the ill results accruing from incom- 
plete intestinal elimination. 

The use of fruits, fresh vegetables, and coarse bread will often accom- 
plish much in relieving constipation. The mineral waters, saline or 
sulpho-saline, solutions of sodium phosphate or Carlsbad salts answer 
admirably. Other efficient laxatives are aloin, podophyllin, and cascara 
sagrada. Rectal enemata should be avoided, and drastic cathartics are 
always objectionable, owing to the danger of causing abortion. Instances 
are rare in which purgation is necessary. 

Urinary Excretion. It is especially important that careful attention 
be directed to the performance of the renal function. The urine should 
frequently receive a careful microscopical and chemical examination, and 
during the last two months of pregnancy should be examined at least 
weekly. Close observation of and the careful regulation of the function 
of the kidneys during gestation is of the utmost importance in the 
prophylaxis of the toxemias of pregnancy. The changes liable to occur 
in the urine of pregnant women have been described in another chap- 
ter. The occurrence of albuminuria should always be regarded with 
suspicion. The most valuable evidence of the emunctory activity of the 
kidneys is the total daily quantity of urinary solids, especially of urea. 
Note should be taken frequently of the daily quantity of urine passed 
and of its specific gravity. Samples for examination should be had 
from the entire amount of urine voided during the twenty-four hours. 
The total daily solids may be estimated approximately by the following 
method : Multiply the last two figures of the number representing the 
specific gravity by the number of ounces for the day. The product 
multiplied by lfo indicates nearly the number of grains of solid matter 
in the given number of ounces. The average daily quantity of solids in 
health is 1000 grains. This, however, is subject to considerable varia- 
tion within physiological limits. 

The quantitative determination of urea is best conducted by Prof. 
Bartley's method, as detailed on p. 212. 

The daily amount of urea is normally 500 grains, yet a great range 
of variation obtains here, too, within the limits of health. It is affected 
by the quantity and quality of food ingested and by the degree of mus- 
cular exertion. 

Albuminuria always calls for the institution of dietetic and other 
remedial measures. 

The Mental Condition of a pregnant woman should always be an 
object of solicitude. With increased emotional susceptibility she may 
be quite excitable, irritable, and be easily disturbed by external influences 
which in the non-pregnant would make no injurious impression. 

It is an interesting question to what extent the unborn child is affected 



156 PHYSIOLOGY OF PREGNANCY. 

!>y the mental condition of the mother. There is do doubt that her 
mental state may be the cause of modifications in the physical, the in- 
tellectual, and the moral characteristics of her offspring. The mental 
hygiene of the mother is, therefore, important. She should be guarded 
from all untoward Influences. Kind assurances are helpful, and judicious 
amusement should be encouraged. The mind is to be pleasantly occu- 
pied. Associations should be agreeable, cheerful. A gentle protective care 
ought to be thrown around the patient, and she should be treated with 
considerate kindness. In the attainment of this desirable environment 
the co-operation of the friends is obviously essential. 

Infectious Exposures. The pregnant woman should be warned of the 
danger that may come from contact with infectious or contagious dis- 
eases. Such exposures are doubly dangerous shortly before labor. While 
pregnancy continues the natural resistance to the specific action of 
pathogenic germs is undoubtedly increased, but after parturition the 
exhaustion of labor and the diminished ingestion of food tend to 
diminish resistance, and the woman becomes an easier prey to infection. 
The diseases with which it is most dangerous for her to come in contact 
are scarlet fever, diphtheria, erysipelas, and all septic conditions. 

Avoidance of Drugs. In all cases as little medicine as possible should 
be administered. Pregnancy as a purely physiological condition is best 
managed by a close observance of judicious hygienic rules. 

Obstetric* Examination. After the foetus is viable it is the duty of 
the obstetrician to make careful examination by the abdomen. In all 
cases an external and generally an internal examination should be made 
toward the last month of pregnancy. The objects of this examination 
are to determine : 

1. Whether or not the woman is actually pregnant. 

2. The duration of pregnancy. 

3. Whether the pregnancy is single or multiple. 

4. Whether the foetus is living. 

5. The presentation and position of the foetus. 

6. The measurements of the maternal pelvis. 

7. The size and hardness of the foetal head. 

8. The possible existence of pelvic or abdominal tumors and of other 
pathological conditions that may injuriously affect the labor. 

9. The probable date of labor. 

10. The obstetric prognosis. 

The precise methods of diagnosis which are carried out in well- 
managed maternities ought also to be the rule in private practice. 
Should the conditions be such as may lead to long and difficult labor, 
the obstetrician should be forewarned, that he may determine in ad- 
vance what course to pursue: whether to choose the induction of prema- 
ture labor, to wait till term and depend upon the use of forceps, to 
resort to podalic version, or symphysiotomy, or a Cesarean section. The 
knowledge gained by the proper study of the obstetric case in ad- 
vance of labor affords the means of saving many maternal and foetal 
lives. 

The obstetric examination will be treated more in detail in connection 
with the management of labor. 



PAET III. 

PHYSIOLOGY OF LABOR. 



CHAPTEE VII. 

THE MECHANICAL ELEMENTS OF LABOR. 

Three factors are concerned in the mechanism of labor. They are : 
1. The Expelling Powers. 2. The Passages. 3. The Passenger. An 
intimate knowledge of these elements of the parturient process is the 
first essential to a proper understanding of the course and management 
of both normal and abnormal labors. 

I. The Expelling Powers. 

The expellent forces are three : a. The contractions of the uterus. 
b. The action of the abdominal muscles, c. The action of the pelvic floor. 

(a) The Uterine Contractions. The chief expelling power is the con- 
traction of the muscular walls of the body of the uterus, or, rather, of 
the upper uterine segment. 

The uterine contractions are involuntary, being mainly under control 
of the sympathetic nervous system. Yet, though independent of the 
will, they may be strengthened, enfeebled, or wholly arrested by emo- 
tional influences. The uterus has two motor centres, one in the medulla 
oblongata and one in the lumbar portion of the cord; apart from these 
its contractions are influenced to some extent by the action of its own 
ganglia. Routh observes that direct communication with the brain 
is not essential to co-ordinate uterine action, though the brain seems 
to regulate the pains. Direct communication between the uterus and 
the lumbar enlargement of the cord is probably essential to co-ordinate 
contraction. 

The contractions are assumed to be peristaltic, the wave beginning at 
the fundus, or at the cornua, and sweeping almost instantaneously over 
the contractile segment. This peristaltic character of the uterine con- 
traction is marked in the tubular uterus of some of the lower animals, 
but is inappreciable in the human species. 

They are also intermittent. At the beginning of labor they recur at 
intervals of about thirty minutes. The intervals shorten as labor pro- 
gresses, and at the acme of expulsion they do not usually exceed two or 

(157) 



158 PHYSIOLOGY OF LABOR. 

three minutes; frequently at the close of the perineal stage they are 
practically continuous. 

The duration of the contraction is about thirty seconds at the onset of 

Labor, and it is gradually Lengthened to sixty seconds, or even more, as 
the expulsive efforts reach their height, variations in both the fre- 
quency and the Length of the contraction, however, are subject to some 
decree of irregularity. The event presents three stages, Contraction, 
Persistent contraction, Relaxation. 

The Strength of the Uterine Contraction varies in different 
women. It differs somewhat in the same person at different stages in 
the progress of labor. Frequently it is observed that each alternate 
contraction is more powerful than the preceding. 

The force of the contraction cannot be definitely stated. According 
to Duncan, the combined power of the uterine and abdominal muscles 
may attain a maximum of fifty, or even eighty, pounds; according to 
Schatz it ranges from seventeen to fifty-five pounds. Poppel, Poullet, 
and Ribemont have reached conclusions nearly similar to those of Schatz. 
The estimates of Duncan, Poppel, and Kibemont are based on the 
force required to rupture the membranes. Schatz measured the down- 
ward pressure exerted during a labor pain by means of a species of 
manometer, but the latter method determines only the force with which 
the head moves, while the propelling power obviously must equal the 
sum of the motion and the resistance. Unfortunately, the tocometric 
methods thus far employed are not wholly reliable. Though we have no 
means of knowing the exact value of a labor pain, it probably never 
exceeds and seldom attains the maximum limit above stated. 

Changes in the Shape and Position of the Uterus. During 
a contraction the uterus assumes approximately a cylindrical form, its 
longitudinal and antero-posterior diameters being increased, while its 
transverse is diminished. In other words, its cross-section takes on a 
more nearly circular shape. The fundus is held forward against the 
abdominal wall, and the entire organ is forced downward. The long 
axis of the uterus is brought in line with that of the pelvic inlet. The 
peritoneal covering adapts itself to the changing shape and size of the 
uterus by reason of its elasticity. The muscular structures of all the 
uterine ligaments doubtless contract simultaneously with those of the 
organ itself, and to some extent they assist in the expulsion of its con- 
tents and also in fixing the uterus. 

(b) The Action of the Abdominal Muscles. The uterine contractions 
alone are concerned in the dilatation of the lower segment of the uterus 
which takes place preparatory to the expulsion of the fcetus. Dilatation 
complete, the action of the uterus is reinforced by that of the abdominal 
walls. At the height of the uterine contraction the woman holds her 
breath, the diaphragm is fixed, and the intra-abdominal pressure is 
increased by the contractile power of the abdominal muscles. This adds 
materially to the expelling force, compressing the active portion of the 
uterus on all sides. The extruding force of the uterine contraction is sup- 
plemented by the general intra-abdominal pressure, and the contents of 
the organ are impelled in the direction of least resistance, downward 
through the expanded cervix. 

Yet the action of the abdominal muscles is not an essential factor 



THE MECHANICAL ELEMENTS OF LABOR. 



159 



in labor in all cases. It is well known that the uterus may expel its 
contents unaided by the accessory powers. This is exemplified in para- 
plegic women and in spontaneous deliveries under anaesthesia. 

Ordinarily the contractions of the abdominal muscles are under control 
of the will. Toward the close of the second stage, owing to the reflex 
effect of painful distention of the passages, they become more or less 
involuntary in character. 

(c) The Action of the Pelvic Floor. The resistance of the pelvic floor 
acts in some degree as an obstacle to the progress of the birth until the 
head is on the eve of expulsion. From this time the muscular tonicity 
of the posterior portion of the floor helps to impel the head forward in 
the direction of the outlet of the soft parts. The same force, too, aids 
in the expulsion from the vagina of the after-coming pole of the foetus 
and in the extension of the placenta. 

II. The Passages. 

Obstetric Anatomy of the Bony Pelvis. 

The pelvis is the strong bony basin which forms the most important 
part of the birth-canal. (Fig. 142.) The term is derived from the 
Greek word Tzeh^, a bowl. The pelvic canal is irregularly funnel- 



FlG. 142. 




The female pelvis. 



shaped and somewhat flattened from before backward, its larger end 
looking upward and forward, its smaller downward and backward, in 
the erect position of the woman. In it are contained the essential organs 
of generation, and through it the child is expelled in the course of labor. 
Upon its relation to the size and shape of the foetal mass depend the more 
important mechanical phenomena of childbirth. An intimate knowledge 



L60 



PHYSIOLOGY OF LABOR. 



of tlif pelvis, as related to the mechanism of labor, affords the "key to 
tin- obstetric an." 

The Constituent Parts of the Pelvis are: the sacrum, the coccyx, and the 
two 088a innominata. Each of these bones, though made up of separate 
segments In infancy, is, with the exception of the coccyx, practically one 
in the child-bearing woman. 

The Pelvic Joints. Of obstetric importance are the pelvic articulations. 
They are the sacro-iliac joints, the sacro-coccygeal joint, and the symphysis 
pnl)i>. 

The Saobo-iliac Joints. In these joints each articular surface is 
invested with a thin plate of cartilage. Small interspaces containing a 
fluid resembling Bynovia are usually observed between the cartiL 
especially in women; rarely these spaees are wholly absent, and even 
when they exist a synovial membrane cannot always be demonstrated. 
In a considerable proportion of cases a true synovial cavity is present 
and the joint is arthrodial in variety. (Browning.) 



Fig. 143. 




Female pelvis, posterior view, showing constituent parts. (Modified from Testut.) 

The ligaments are the anterior sacro-iliac, the posterior sacro-iliac, 
and the interosseous ligament. 

The anterior sacro-iliac ligament is made up of numerous thin and 
comparatively weak ligamentous bands. 

The posterior sacro-iliac ligament is of great strength and importance. 
It consists chiefly of three fasciculi: the two superior run in a nearly 
horizontal direction from bone to bone; the inferior extends obliquely 
downward and inward from the posterior superior spine of the ilium to 
the third and fourth pieces of the sacrum. The latter is the oblique sacro- 
iliac ligament. 

The interosseous ligament consists of separate bands of fibrous tissue 
extending between the articular surfaces. This is not always present. 

The Sacro-coccygeal Joint. This joint has an interosseous fibro- 
cartilage which permits recession of the coccyx. Its ligaments are four, 



THE MECHANICAL ELEMENTS OF LABOR. 



161 



one at each aspect of the joint. The articulations of the coccygeal seg- 
ments usually retain some degree of mobility upon one another during 
the child-bearing period. 

The Symphysis Pubis. The articular surfaces of the pubic bones 
are united by a disk of fibrous tissue and fibro-cartilage. This inter- 
pubic disk is slightly wedge-shaped, being thickest at its inferior margin, 
and thicker above than below. A small cavity is frequently present in 
the interosseous disk; it is produced by absorption of the fibro-cartilage, 
and is never synovial in character. (Browning.) It is oftenest observed 
in the female. 

There are four pubic ligaments, one on each aspect of the joint. 

The anterior pubic ligament consists of two sets of superficial fibres, 

Fig. 144. 




Os innominatum before fusion of its three constituent parts. (Ribemont-Dessaignes and Lepage.) 
II. Ilium. Is. Ischium. P. Pubis. 



each running obliquely downward across the joint from one pubic 
bone to the other, and of a deep layer which stretches directly across the 
symphysis. The fibres of the latter are blended with the subjacent fibro- 
cartilage. 

The posterior pubic ligament is essentially a layer of thickened perios- 
teum which passes from the posterior surface of one pubic bone to that 
of its companion. 

The superior pubic ligament is a thin bundle of fibres which connects 
the upper aspect of the bones. 

The inferior pubic ligament, the ligamentum arcuatum, is a stout, 
strong, fibrous bundle arching across from the inferior margin of one 

11 



1,;2 PHYSIOLOGY OF LABOR, 

descending pnbio ramus to the other. It Mend- at the median line with 
the interpubic disk. 

Mobility of the Pelvic Joints. A barely perceptible mobility of the 
pubic hones upon each other is generally present in the last weeks of 
gestation. Experience in symphyseotomy lias shown that the sacro-iliao 
articulations are sufficiently movable to permit a separation of the pubic 
bones to the extent of 5 to 7.6 cm., 2 to 3 inches, without injury to the 
anterior ligaments. The sacrum, too, is capable of rotation in some 
degree on a transverse axis drawn through its base a little below the 

level of the promontory. Not only is there a hinge-like motion ;it the 

sacro-coccygea] joint, but the segments of the coccyx, as already stated, 
have some degree of mobility upon one another. Owing to the swelling 
of the interarticular structures, which obtains in all the pelvic articu- 
lations toward the close of pregnancy, some expansion of the pelvic 
planes is possible during labor under the wedge-like action of the fcetal 
head. 

The False and the True Pelvis. The bony pelvis presents two divisions 
— the false and the true pelvis, or the greater and the lesser pelvis. The 
dividing plane cuts the upper anterior margin of the sacrum, the upper 
end of the symphysis pubis, and the ilio-pectineal line on either side. 
The part above this plane is the false, that below the true, pelvis. 

The false pelvis } together with the vertebral column and the abdominal 
walls, forms a funnel-shaped approach to the true pelvis. The space 
included is a part of the abdominal cavity. 

The true pelvis. It is with the true pelvis that obstetric problems have 
mainly to deal. Here it is that the principal resistance to the birth is 
encountered, and here the more important mechanical phenomena of 
labor are executed. Upon a clear comprehension of the anatomy of 
this part of the pelvis in its relation to the parturient process the skill 
of the obstetrician will largely depend. 

The Brim, Inlet, Superior Strait, Isthmus, or Margin of the True Pelvis. 
The anatomical inlet is located by the upper margin of the sacrum, the 
ilio-pectineal lines, and the upper end of the symphysis. Its outline is 
generally described as approximately heart-shaped. Its contour corre- 
sponds nearly to that formed by two ellipses overlapping anteriorly 
each of these ellipses representing the engaging sectional plane of the 
foetal head. In exceptional cases the brim is an irregular oval or is 
nearly round in shape. 

Obstetric Landmarks at the Brim. Certain anatomical points about the 
pelvic inlet are frequently referred to as landmarks, both in obstetric 
writings and in practice. They are : 1. The sacro-vertebral angle, or the 
promontory of the sacrum. The angle is formed by the inclination of 
the pelvis, the intervertebral cartilage between the last lumbar and the 
first sacral vertebrae being wedge-shaped, with its base to the front. 
(Fig. 147.) 2. The sacro-iliac joints, or rather the points at which they 
are met by the ilio-pectineal lines. 3. The ilio-pectineal eminences 
situated on the pubic bones close to the ilio-pubic junctions. 4. The 
symphysis pubis. 

The Outlet or Inferior Strait of the Pelvis. The anatomical outlet of 
the pelvis is bounded by the summit of the subpubic arch, the ischial 
tuberosities, and the tip of the coccyx. The outline is that of a lozenge- 



THE MECHANICAL ELEMENTS OF LABOR. 



163 



shaped figure whose angles have been rounded. (Fig. 145.) Owing to 
the distensibility of the sciatic ligaments, to the yielding character of the 
coccyx, and, to some extent, of the sacro-iliac joints, the contour of the 
outlet becomes ovate at the expulsion of the head. (Fig. 146.) 



Fig. 145. 




Outlet of pelvis. 



It will presently be seen that the superior and the inferior strait in 
the obstetric sense are not identical with the anatomical brim and outlet 
respectively. 

Obstetric Landmarks at the Outlet. Anatomical points about the outlet 
which are of special importance as obstetric landmarks are the following: 

1 . The tip of the coccyx, and of the sacrum. 

2. The subpubic arch. 3. The ischial tuber- 
osities. 4. The ischial spines. 5. The ob- 
turator foramina. 

Sacro-sciatic Ligaments. The greater and 
the lesser sacro-sciatic ligaments contribute 
to the formation of the more resistant por- 
tion of the parturient canal, which is mainly 
formed by the bones. 

The greater sacro-sciatic ligament arises 
from the posterior inferior spine of the ilium 
and from the side of the sacrum and coccyx, 
narrows and thickens in the middle of its 
length, broadens again at its anterior attach- 
ment, and is inserted into the inner surface 
of the ischial tuberosity, sending forward a 
falciform process upon the ischial ramus. 
(Fig. 147.) 

The lesser sacro-sciatic ligament takes its origin from the side of the 
sacrum and of the coccyx, and passing in front of the greater is inserted 
into the spine of the ischium. (Fig. 147.) 

The open spaces between the greater and the lesser sciatic notches and 
the ligaments are respectively the greater and the lesser sciatic foramina. 

The Cavity of the True Pelvis is bounded posteriorly in the main by the 
sacrum and the coccyx, anteriorly by the pubic bones and their rami, 
laterally by the lower portions of the ilia and the bodies, tuberosities, 




The outlet as seen from below. 
C. Under surface of the coccyx. 
A P. The antero-posterior, or pubo- 
coccygeal diameter. TE. Transverse 
diameter. R and L 0. Right and 
left oblique diameters. 



164 



VUYSIOLOOY OF LABOR. 



spines, and rami of the ischial bones. It is irregularly cylindrical in 
shape. The posterior wall is smooth, and is concave from above down- 
ward; it- depth, measured on the curve of the sacrum and coccyx, is 

1 1 ,6 tO 1 2.5 cm., II to 5 inches. 

The anterior wall is smooth and concave from side to side; at the 
symphysis it- depth is 1 em., or a little more, 1-| inch. The lateral 
Walls corresponding to the broad smooth surfaces of the ischial hones 

are 9 em. in depth, :\\ inches. It will he noted that in the passage of 
the head through the pelvis its posterior pole traverses a much greater 
distance than does the anterior before it escapes from the bony canal. 
As will be seen later, the difference in the extent of the posterior and the 
anterior walls in the soft parts which make up the lower portion of the 
birth-canal is even greater than in the osseous portion of the parturient 
tract. 

Fig. 147. 




Interior surface of left half of pelvis. (Modified from Farabeuf and Varnier.) 
1. Promontory of sacrum. 2. Anterior superior iliac spine. 3. Iliac fossa. 4. Anterior inferior 
iliac spine. 5. Lateral surface of pelvic cavity. 6. Symphysis pubis. 7. Tip of sacrum. 8. First 
piece of coccyx. 9. Spine of ischium. 10. Ischium. 11. Lesser sacro-sciatic ligament. 12. Greater 
sacro-sciatic ligament. 13. Lesser sacro-sciatic foramen SF. Greater sacro-sciatic foramen. OF. 
Obturator foramen. 



Obstetric Planes of the Pelvis. The short curved canal, bounded by 
the bony walls just described, varies somewhat in shape and in size at 
different parts of its course. These variations are best understood with 
the aid of a series of planes drawn transversely through the pelvic cavity 
at different levels. Three are of special obstetric importance. These 
are the plane of the brim, the plane of the outlet, and the middle plane. 



THE MECHANICAL ELEMENTS OF LABOR. 



165 



By the dimensions of these planes the presence or absence of deformity 
in the canal may usually be determined. 

Plane of the Pelvic Brim. The obstetric inlet is the space 
available for the passage of the head at the superior strait. It is not 
strictly coincident with the anatomical brim. The latter is the entrance 
of the lesser pelvis, the former the level of least expansion at the upper 
portion of the pelvic canal. The plane of the obstetric inlet is located 
by the summit of the sacral promontory, the ilio-pectineal line, and the 
posterior surface of the symphysis at a point about 1 cm., § of an inch, 
below its upper margin. (Fig. 148.) 

Fig. 148. 




The diameters of the pelvis. Shows also location of anatomical and obstetric inlet and outlet. 



Plane of the Pelvic Outlet. The structures which bound the 
anatomical outlet of the pelvis posteriorly are not wholly fixed, but they 
yield somewhat during labor under pressure of the advancing head. 
The plane of greatest bony resistance at the inferior strait, therefore, is 
not that of the anatomical outlet, but a plane somewhat above it. The 
latter is the inferior strait from the obstetric stand-point. For the ob- 
stetrician the plane of the pelvic outlet is one denned by the tip of 
the sacrum, the ischial tuberosities, and the posterior surface of the 
pubic symphysis at a point immediately above its lower margin. At the 
expulsion of the head from the bony outlet, owing to the yielding char- 
acter of the sciatic ligaments, the shape of this plane becomes ovate, 
with its greatest expansion directed posteriorly. 

_ The Middle Plane. This plane cuts the upper end of the third 
piece of the sacrum, the middle of the symphysis pubis, and points 



166 



PHYSIOLOGY OF LA noil. 



opposite the centres of the acetabular cavities. The latter plane is 

somewhat larger, the plane of the inferior Btrail B little smaller than 
that of the pelvic brim. 

Inclination of the Pelvis. The plane of the pelvic brim forms an angle 
with the horizon of from 60 to 60 degrees, according to the posture of 
the body. The upper margin of the symphysis pubis in the erect posi- 




Diagram showing axis and planes of pelvis. 
A BCD. Axis of entire parturient canal. X. Anus as distended at acme of expulsion. EF. Plane 
of brim. KL. Mid-plane of cavity. MN. Plane of outlet. OP. Axis of brim. QR. Axis of mid- 
plane. S T. Axis of outlet. H H. Horizon. EN. Diagonal conjugate diameter. 

tion of the woman is nearly 9 cm., 3 J inches, below the level of the 
promontory. The coccyx is 2 cm. above the level of the subpubic arch, 
the pubo-coccygeal line making an angle of 10 degrees with the horizon. 
The direction of the pelvic canal at the inlet turns sharply backward 
from the body axis. Yet it must be remembered that the inclination of 
the pelvis is subject to considerable variation in different postures of the 
body. 



THE MECHANICAL ELEMENTS OF LABOR. 



167 



The Pelvic Diameters and Measurements. 

The varying size and shape of the bony canal at different levels are 
indicated by the varying dimensions of the horizontal planes of the pelvis. 
These dimensions are measured on each plane in four directions : ^ the 
antero-posterior, the transverse, and the two oblique. The several diam- 
eters of these planes taken together are spoken of as the internal diame- 
ters of the pelvis. 

Fig. 150. 




Obstetric diameters of the pelvic brim. 

A A'. Conjugate diameter. T T'. Transverse diameter. L O. Left obiique diameter. 

R O. Right oblique diameter. 



Internal Diameters of the Static or Dried Pelvis. 

At the Brim. The Antero-posterior Diameter at the brim is the 
least distance between the sacral promontory and the pubic symphysis. It 
represents the available interval between the two surfaces for the passage 
of the head. It extends from the middle of the sacral promontory to 
the posterior surface of the symphysis at a point about two-fifths of an 
inch below its upper margin. It is termed the conjugate, or the true 
conjugate, and its value is 11 cm., 4f inches. (Fig. 150.) 

The Transverse Diameter is the greatest distance between the 
ilio-pectineal lines, and measures 13.5 cm., 5 \ inches. The greatest 
transverse diameter of the pelvic brim, however, lies too near the pro- 
montory to be available for the passage of any of the conventional 
diameters of the foetal head. In a typical relation of head to pelvis, 
therefore, the head never passes in transverse position. (Fig. 150.) 

The Oblique Diameters extend, one from the right, the other from 
the left sacro-iliac joint at its intersectiou with the ilio-pectineal line, to 
the opposite ilio-pectineal eminence. The right oblique springs from 
the right, the left oblique from the left sacro-iliac articulation. Their 
values are each about 12.5 cm., 5 inches. (Fig. 151.) The right 
oblique diameter is slightly longer than the left. It should be noted 



168 



PHYSIOLOGY OF LABOR. 



that by French writers fchie nomenclature of the oblique diameters is 
reversed, the left oblique being that which ends at the left and the right 
oblique that which ends at the right anterior aspect of the pelvic brim. 
At the Middle Plane. Tin-: ANTERO-POSTERJOB DlAMETEB is the 

distance from the upper margin of the third piece of the sacrum to the 
posterior surface of the symphysis pubis at the middle point of its depth, 
and [fi L2.5 cm., 5 inches. 

Tin: Transverse Diameter is the greatest transverse width of the 

pelvis at this plane, and measures 12 em., 4{ inches. 

The Oblique DIAMETERS are not measured from fixed points, and 
are, therefore, valueless for obstetric purposes. 

Pig. 151. 




Obstetric diameters of the pelvic outlet. 
S. P. Sacro-pubic diameter. Bi. I. Bisischial diameter. Bi. S. Bisciatic diameter. 

At the Outlet. The Anteroposterior Diameter of the obstetric 
outlet is a line drawn from the tip of the sacrum to a point just above 
the summit of the subpubic arch. Its value is 11.5 cm., 4 J inches. 

The Greatest Transverse Diameter is the bisischial line, and 
is 11 cm., 4f inches. It is measured from the inner surface of the 
ischial tuberosities at the middle of their posterior borders, and corre- 
sponds in the living pelvis to a line running transversely through the 
anterior margin of the anal orifice. The antero-posterior diameter of 
the anatomical outlet extends from the tip of the coccyx to the summit 
of the subpubic arch, and measures 9 cm., 3 J inches. The distance be- 
tween the ischial spines, the bisischiatic diameter, is 10.5 cm., 4J inches. 

The oblique diameters at the outlet are of little practical importance, 
since their posterior extremities do not rest on fixed points. (Fig. 151.) 



Measurements of the Dynamic Pelvis. 

Internal Measurements. The dimensions thus far stated relate to the 
anatomical or dried pelvis. In the pelvis of the living woman — the 
dynamic pelvis — the measurements are more or less modified by the 



THE MECHANICAL ELEMENTS OF LABOR. 



169 



presence of the soft structures which line the bony canal. The internal 
diameters are all diminished from an eighth to a quarter of an inch by 
the thickness of the soft parts. 

At the brim, owing to the encroachment of the ilio-psoas muscles upon 
the pelvic space, the transverse diameter is reduced still more, so that, 
while in the anatomical pelvis the transverse is the longest dimension at 
the inlet, the oblique is greatest in the obstetric patient. (Fig. 152.) 

Fig. 152. 




Diameters of the pelvic inlet as affected by the principal soft parts. The oblique is the longest 
practicable diameter in the dynamic pelvis. (Farabeuf.) 



External Measurements. The external bear a fairly constant relation 
to the internal dimensions of the pelvis. External measurements are, 
therefore, useful to the obstetrician in determining the probable capacity 
of the pelvic canal. They are especially valuable for the reason that 
they may be more readily and more accurately determined in the living 
subject than can the iuternal diameters. The more important external 
measurements are : The External Conjugate Diameter, or Diameter of 
Baudelocque, the Interspinal, and the Intercristal Diameters. 

The External Conjugate Diameter is the distance from the 
fossa immediately below the spine of the last lumbar vertebra to the most 
prominent point on the anterior surface of the pubes, two-fifths of an 
inch below the upper margin of the symphysis, and its value is 20.3 
cm., 8 inches. 



170 PHYSIOLOGY OF LABOR. 

The external conjugate is obviously subject to considerable variation, 

dependent OD the thickness of the bony structures and of the overlying 
parts. The difference between the external and the internal conjugate 

ranges Uom 7 to 12.7 cm., 2J to 5 inches, the average being ( J cm., 3) 

inches. 

THE [NTEBSPINAL DlAMETEB is the distance between the outer 
aspects of the anterior spines of the ilium, measured from the outer 
margins of the insertion of the sartorii, 25.5 cm., 10 inches. 

The [ntebcbistal Diameter is the greatest distance between the 
outer borders of the iliac crests, 28 cm., 11 inches. 

In addition to these may be mentioned the external oblique diameters; 
they are respectively the distance from the posterior superior spine of one 
to the anterior superior spine of the opposite iliac bone, 22 cm., 8| inches. 

The Bisischial Diameter, 11 cm., 4 J inches, since it may be 
measured externally as well as internally, may be enumerated with the 
external diameters. The bitrochanteric diameter, which is the distance 
from one trochanter major to its companion, is usually included with 
the pelvic measurements. Its value is 31 cm., 12 J inches. 

It will be seen by comparing the dimensions of the different planes 
that the pelvic canal grows progressively narrower in its transverse 
diameter from the brim to the outlet, the difference at these two levels 
amounting to 2.5 cm. In the sagittal direction the canal is narrowest 
at the brim and most roomy at the middle plane. The antero-posterior 
diameter at the middle plane is 1.5 cm. longer, at the inferior strait it is 
5 cm. longer than at the inlet. 

The following tabular statement of the pelvic measurements will be 
found convenient for reference : 

Summary of Internal Measurements of the Dried Pelvis. 

Antero-posterior diameters. Oblique diameters. Transverse diameters. 

Brim . . 11cm., 4% inches. 12.5 cm., 5 inches. 13.5 cm., 534 inches. 

Mid-plane . 12.5 cm., 5 inches. 12 cm., 424 inches. 12 cm., 4% inches. 

Outlet . . 11 5 cm., 4% inches. 11cm., 4% inches. 

Circumference of the brim, 40 cm., 16 inches ; of the outlet, 33 cm., 13 inches. 

Summary of External Measurements of the Dynamic Pelvis. 

External -conjugate diameter 20.3 cm., 8 inches. 

Interspinal 25.5 " 10 " 

Intercristal 28 11 

Bitrochanteric 31 12.4 " 

External oblique 22 8% " 

Bisischial 11 " 4% " 

The average external circumference of the pelvis measured over the 
symphysis, just below the iliac crests, and across the middle of the sacrum 
is one yard. 

The internal diameters of the dried pelvis, as stated in the following 
table, are sufficiently exact for practical purposes, and they have the 
advantage of being easily remembered : 

Approximate Internal Measurements of the Pelvis. 

Antero-posterior. ObliqiLe. Transverse. 

Brim 4 inches. 4% inches. 5 inches. 

Mid-plane ...... 4% " 4% 4>£ " 

Outlet 5 " 4% " 4 " 



THE MECHANICAL ELEMENTS OF LABOR. 



171 



Differences Between the Male and the Female Pelves. 

Until the age of puberty the pelves of the opposite sexes present no 
striking differences of structure. The distinctive peculiarities of the 




Female pelvis. 



Fig. 154. 




Male pelvis. 



female pelvis are, in the main, developed after that period. In the 
mature woman the distinguishing marks of the pelvis as compared with 
that of the male are chiefly these : 



172 PHTSIOLOQ V OF LA lion. 

Asa whole, the bones are Lighter and more slender. The false pelvis is 

somewhat smaller and the true pelvis larger in all diameters and of 

shallower depth. 

The brim is less triangular and its capacity greater, the sacro-vertebral 
angle i- more prominent. The ilio-pectineal Lines arc more strongly 

Carved, and the pubic spines are farther apart. 

The cavity is less funnel-shaped, and all its horizontal diameters are 
greater. The sacrum IS shorter and broader, and it presents a more 
nearly uniform antero-posterior curvature. 

The outlet is Larger; the width of the subpubic arch is greater, 80 to 
100 degrees or more, the angle in the male measuring from 70 to 80 
degrees. The depth of the symphysis pubis is less. 

Differences Dependent on Racial Characteristics. 

Marked differences in the form and size of the pelvis obtain in differ- 
ent races. Yet these variations of type are largely due, as Spiegelberg 
has intimated, to conditions of nutrition and activity. 

Pelvic deformities are most frequent in the inferior races. A larger 
proportion of dwarfed pelves is observed in races of a low order of 
physical development. A common deviation from the normal Caucasian 
type consists in a relative elongation of the antero-posterior dimensions 
of the pelvis as compared with the transverse. Thus the pelvis of the 
Australian is nearly circular in horizontal outline, and in Bush women 
the antero-posterior exceed the transverse diameters. The pelvis of the 
Laplander is small. 

Obstetric Anatomy of the Soft Parts of the Parturient Tract. 

The Uterus forms a part of the parturient canal. Yet, as will be seen 
in connection with the physiology of labor, the organ resolves itself into 
two segments which sustain very different relations to the parturient 
process, an upper, contractile, and a lower, passive, segment. The upper 
segment is of interest chiefly as the principal source of the propelling 
power, the lower, the seat of resistance at the beginning of labor, belongs 
more properly to the passages than does the contractile portion of the 
organ. 

The Soft Parts of the Pelvis which concern the obstetrician are chiefly 
the muscles which line the bony excavation and the structures which 
compose the pelvic door. The former, as already stated, reduce slightly 
the capacity of the bony cavity; the latter supplement the osseous por- 
tion of the parturient tract. Lying immediately above the lateral mar- 
gins of the brim, the iliacus and psoas muscles diminish the transverse 
width of the bony inlet to the extent of about a quarter of an inch on 
each side. The external iliac vessels run along the inner borders of these 
muscles. The main trunk of the lumbar plexus follows the course of 
the psoas, and the crural nerve runs between the psoas and the iliacus 
muscles. 

The median portion of both the anterior and the posterior pelvic walls 
is devoid of muscular coverings. On either side of the median section 
lie the pyriformis posteriorly and the obturator internus anteriorly and 



THE MECHANICAL ELEMENTS OF LABOR. 173 

laterally. These muscles are thin and are so located as scarcely to lessen 
appreciably the capacity of the pelvis. 

The Pyriformis is a fan-shaped muscle arising by digitations from 
the anterior aspects of the second, third, and fourth sacral vertebrae, 
from the upper margin of the greater sciatic notch, and from the ante- 
rior surface of the greater sacro-sciatic ligament; it passes out of the 
pelvis by the greater sacro-sciatic foramen to its insertion in the femur. 
The nerves of the sacral plexus lie in front of this muscle. 

The Obturator Internus Muscle arises from the inner surface of 
the obturator membrane, from the fibrous arch which completes the canal 
for the obturator vessels and nerves, and from the inner surface of the 
innominate bone anteriorly between the obturator foramen and the 
margin of the ischio-pubic ramus, and laterally over an area extending 
backward to the sciatic notch, upward to the brim, and downward to 
the outlet; a few fibres arise from the obturator fascia which covers the 
internal surface of the muscle; its fibres converge and pass out through 
the lesser sacro-sciatic foramen to be inserted into the great trochanter. 

The Bladder in the front portion of the pelvic cavity does not when 
empty appreciably diminish its capacity. Moreover, during the begin- 
ning stage of labor, as will be explained later, the greater portion of this 
viscus is drawn up above the inlet of the pelvis. 

The Rectum at the brim lies in front of the left sacro-iliac joint; it 
then runs inward to descend in the median line along the anterior sur- 
face of the sacrum and the coccyx. It encroaches but little on the pelvic 
space except when distended, yet the left oblique diameter at the brim, 
which in the dried pelvis is shorter than the right, is rendered still more 
so by the presence of the rectum, especially when the latter is filled. 
The greater frequency with which the head enters the pelvis in the 
right oblique diameter than in the left is explained by these facts. 

The Pelvic Floor comprises the soft structures Avhich close the 
outlet of the bony pelvis and give support to the pelvic and abdominal 
contents. Its upper limit is the peritoneum except where that structure 
is lifted off to be reflected over the pelvic viscera. Its lower surface 
is the skin. At its median portion it is obliquely traversed by three 
muscular slits, the urethra, the vagina, and the rectum, all approxi- 
mately parallel with the pelvic brim, save that the lower end of the 
rectum turns backward nearly at a right angle with the vagina. 

The posterior vaginal wall and the soft structures behind it constitute 
the sacral segment ; the anterior wall of the vagina and the soft parts in 
front of it compose the pubic segment of the pelvic floor (Hart). 

In labor the pubic segment of the floor is drawn upward and the 
sacral segment is distended and thrust downward as the foetus descends 
through the infra-osseous portion of the parturient canal. The resiliency 
of the posterior segment of the floor holds the foetal mass in close relation 
with the ischio-pubic rami during the completion of the birth, and assists 
in its final expulsion. 

Measurements. In the nullipara the distance from the coccyx to the 
anus is 4.5 cm., If inch; from the anus to the lower margin of the 
vulvar orifice, 3.2 cm., 1^ inch; in the parous woman the latter distance 
is 2.5 cm., 1 inch; in the primigravida at term, 3.8 cm., 1J inch. The 
greatest transverse width of the pelvic floor, on the bisischial line, is 



174 



PHYSIOLOQ V OF LABOR. 



11 cm., 4| inches; the perpendicular thickness at the anus is about 6 
cm., 2 inches. In the non-gravid woman the average projectioo below 

a line drawn from the tip of the 0OCCV3 to the Blinunit of the subpubic 

arch is abort -.-") cm., l inch. The Length of the sacral segment during 

labor at the acme of expulsion — coccyx to lower edge of vulvar orifice — 

is 1 5 cm., <! inches. 

The more important component parts of the pelvic floor are it< mus- 
cular structures and fascia) sheets. On the latter its strength and 
supporting power mainly depend. 

For a detailed description of the anatomy of the pelvic floor the reader 
is referred to the chapter on The Female Pelvic Organs. 



Fig. 155. 



Fig. 156. 




Axis of the bony pelvis. 
c d. Axis of inlet, cf. Axis of bony pelvis. 



Axis of the birth-canal, 
r. Anus, a 6. Plane of outlet of com- 
pleted canal, e. Perpendicular to plane 
or axis of expulsion. 



The Parturient Axis. It is obvious that an infinite number of pelvic 
planes may be drawn in addition to the cardinal planes previously 
described. All, if extended, would meet in front of the pubic joint. 
The mathematical axis of the pelvic canal is a line which pierces each 
of these planes perpendicularly at its centre point. Such a line is a 
curved line with its concavity forward, and it represents very nearly 
the course which the foetal head follows in its descent through the 
pelvis in typical labors. The axis of the inlet prolonged strikes the 



THE MECHANICAL ELEMENTS OF LABOR. 175 

tip of the coccyx and a point on the abdominal wall near the umbilicus. 
The axis of the obstetric outlet of the bony pelvis if extended would 
pass immediately in front of the sacral promontory. The plane of the 
vulvo-vaginal ring at the moment when the foetal head is expelled is 
nearly parallel with the long axis of the mother's body. The outlet of 
the soft parts, therefore, at the acme of expulsion, looks almost directly 
forward. (Figs. 155 and 156.) 

III. The Foetus. 

The head, the upper part of the trunk, and the breech of the foetus 
each fills the pelvis more or less completely during its passage through 
it, and each has sufficient rigidity to retain its primal shape in some 
degree during labor. These parts of the foetal mass, therefore, all sus- 
tain an important relation to the mechanism of labor. The head, how- 
ever, is much larger in proportion to the trunk in the foetus than in the 
adult. As a whole, its diameters are greater than those of the shoulders 
or the breech and thighs, and are more incompressible. It follows that 
the principal resistance to the passage of the child through the pelvis 
is offered by the head. While the body of the foetus cannot be wholly 
neglected in the study of the mechanism of labor, it is with the head 
that obstetric questions are mainly concerned. 

Obstetric Anatomy of the Foetal Head. For the obstetrician the foetal 
head present two general divisions: 1, the cranial vault; 2, the cranial 
base and face. The former, owing to the semi-cartilaginous character 
and the mobility of its bones, is plastic, a fact of great importance in 
facilitating the passage of the head through the pelvis; the latter is 
firm and unyielding, its bony structures being more highly ossified and 
more firmly united. Protection is thus afforded during birth to the 
ganglia at the base of the brain. 

It is necessary to bear in mind, however, that the plasticity of the foetal 
head differs in different infants at term. The degree of ossification and 
the firmness of union between the cranial bones in the fully developed 
foetus are subject to considerable variation, and the hardness of the head 
is an essential element in the labor. 

The Bones of the cranial vault are the two parietal, the two frontal, 
and the squamous portion of the occipital and of the two temporal bones. 
They are united only by the unossified external periosteum and by the 
dura mater. Both the flexible character of the bones and the existence 
of membranous interspaces contribute to the plasticity of the cranial vault. 

The Sutures of the vault are the membranous intervals between two 
adjacent bones. Those of obstetric importance are the sagittal or inter- 
parietal, the frontal or interfrontal, the coronal or fronto-parietal, the 
lambdoidal or occipifo-parietal sutures. (Figs. 157 and 158.) 

The Fontanelles are the greater spaces formed by the Avidening 
out of the sutures between the angles of three or four adjacent bones. 

The anterior fontanelle, or bregma, is situated at the junction of the 
sagittal, the coronal, and the frontal sutures. It is identified in the 
vaginal examination during labor by the following characters. It is 
kite-shaped, or quadrangular, with its most acute angle forward. Its 
average diameter is one inch. Its size, however, varies in different 



176 



PHYSIOl (X, Y OF LABOR. 



fu'tal heads, and is inucli diminished by overlapping of the bones when 

the head is firmly wedged in the peh is. Four Lines of sutures run into it. 

Tin posterior fonia/nelle is formed at the junction of the sagittal and 

the Lambdoidal sutures. 



Fig. 157. 



It presents to the examining finger the follow- 

Fig. 158. 





Anterior and posterior fontanelles, sagittal, lambdoidal, coronal, and frontal sutures. 

ing distinguishing marks : It is small, usually a mere depression, barely 
perceptible to the finger-tip. Three lines of suture run into it. Behind 
it is the squamous or triangular portion of the occipital bone, which is 
movable upon the basilar portion by a hinge-like joint of fibrous tissue. 

Fig. 159. 




Foetal head seen from above, showing false fontanelle between the anterior and the posterior 
fontanelle. (After Ribemont-Dessaignes and Lepage.) 

In exceptional instances in well-ossified heads this fontanelle is absent. 
Frequently during labor the interspace is obliterated by the crowding 
together or overlapping of the cranial bones. 

Temporal Fontanelles. A fontanelle exists on either side of the head 



THE MECHANICAL ELEMENTS OF LABOR. 1 77 

at the junction of the temporal with the parietal and occipital bones. 
They are of little obstetric interest, except for the fact that in rare cases 
one of them may fall within reach of the examining finger and be mis- 
taken for the occipital fontanelle. 

False Fontanelles, due to failure of ossification, are exceptionally 
observed either in the body of the bone or in the course of a suture. 
(Fig. 159.) 

Wormian Bones. Rarely there are small, supernumerary bones in the 
interparietal space. They are the result of irregular ossification, and are 
known as Wormian bones. 

In the examination of the head for diagnosis of position, the practi- 
tioner must have in mind the possibility of being misled by these anomalies. 

Protuberances. The cranial bones present five protuberances which 
are of interest as obstetric landmarks. They are the occipital, the two 
parietal, and the two frontal. The occipital protuberance is situated 2.5 
cm., 1 inch, or more behind the posterior fontanelle. The parietal pro- 
tuberance or boss is the bony eminence at the centre of each parietal bone. 
The frontal protuberance is the eminence at the centre of each frontal bone. 

The Vertex is that portion of the head between the anterior and the 
posterior fontanelles and extending laterally to the parietal eminences. 

The Occiput is the part of the head behind the posterior fontanelle. 

The Sinciput is that portion of the cranial vault in front of the 
bregma. 

Fig. 160. 




T 

The diameters of the foetal head. (Farabeuf and Vae^er.) 

F. Occipitofrontal. O B. Suboccipito-bregmatic. B T. Trachelo-bregmatic. The maximum 

diameter, occipito-mental, is indicated by the long dotted arrow. Measurements are in centimetres. 

Measurements of the Foetal Head. Obviously the obstetrician must take 
into account the shape and dimensions of the foetal head, as well as of 
the pelvis. Xot only the size, but the configuration of the cephalic mass 
is an essential element in the relation of the head to the birth-canal. 
These elements in the obstetric problem are best understood with the aid 
of a series of head diameters and circumferences measured in different 

12 



17s 



PHYSIOLOGY OF LABOR. 



planes. The diameters of the head commonly made nse of are the 
occipitofrontal, the oocipito-mental, the suboccipito-bregmatic, the 
biparietal, the bitemporal, the bimastoid, the fronto-mental, and the 
traohelo-bregmatic. (Figs. L 60 and 161.) 

The occipitofrontal diameter is measured from the tip of the occipital 
protuberance to the roof of the nose. 

The ocmpito-menial diameter extends from the occipital protuberance 
to the centre of the lower margin of the chin. 

The dubocoipito-bregmedic diameter extends from the junction of the 

nucha and the occiput to the centre of the bregma. 

The suboccipito-frontal extends from the junction of nucha and occiput 
to the summit of the forehead. 

The biparietal diameter is measured through the centres of the parietal 
eminences. 

Fig. 161. 




Engaging diameters of the flexed head. (After Farabeuf and Varnier.) 
P P. Biparietal diameter, 9 cm. B. Suboccipito-bregmatic diameter, 9.5 cm. 



The bitemporal is the distance between the lower extremities of the 
coronal suture. 

The bimastoid is the distance between the mastoid apophyses. 

The fronto-mental diameter extends from the summit of the forehead 
to the centre of the lower margin of the chin. 

The cervico-bregmatic extends from the junction of neck and chin to 
the centre of the bregma. 

The average values of these diameters are given in the following table: 



Average Diameters of the Fcetal Head. 



Occipitofrontal diameter 11.5 cm. 

Occipito-mental " 14 " 

Suboccipito bregmatic diameter 9.5 " 

Suboccipito-frontal " 11 " 

Biparietal diameter 9.5 " 

Bitemporal " 8 " 

Bimastoid " 7 " 

Fronto-mental diameter 9 " 

Trachelo-bregmatic diameter 9.5 " 



4>£ inches. 

*% " 

3% " 

V/s " 

2% " 

3% « 



THE MECHANICAL ELEMENTS OF LABOR. 179 

Approximate Diameters of the Fcetal Head. The approxi- 
mate diameters of the foetal head may for easy memorizing be stated with 
sufficient accuracy for practical purposes as follows : 

Biparietal 9 cm. 3% inches. 

Suboccipitobregmatic 9 " %% " 

Fronto-mental 9 " 3% 

Occipitofrontal . . . . • . . . 11.5 " 4% " 

Occipito-mental 14 5% " 

Planes of the Foetal Head. Just as the pelvis is studied with the aid of 
the horizontal planes, so the size and shape of the head in its relation 
to the birth-canal may more easily be appreciated with the help of cross- 
sections made through its more important diameters. Most useful for 
this purpose are the occipito-mental section through the biparietal and 
the occipito-mental diameters, the occipitofrontal section through the 
biparietal and the occipito-frontal diameters, the suboccipito-frontal 
through the bitemporal and the suboccipito-frontal diameters, the sub- 
occipito-bregmatic through the biparietal and the suboccipito-bregmatic 
diameters. By comparison of these sectional planes it will be seen that 
the suboccipito-bregmatic plane, which is the plane that falls in relation 
with the different pelvic planes successively as the head descends, is not 
only the smallest but is nearly circular. It measures, after the head is 
well moulded to the pelvis, 9 cm., about 3 J inches, in the biparietal, 
and but little more in the opposite diameter. Its circumference is about 
33 cm., 13 inches, while the occipito-frontal circumference is 34.5 cm., 
13J inches, and the occipito-mental 35.5 cm., 14 inches. The sub- 
occipito-bregmatic is the plane which engages in complete flexion of the 
head. Thus it is obvious that the difference between a fully flexed and 
a partially extended head may make all the difference between an easy 
and an impossible delivery. 

Circumference of the Foetal Head. The cross-sections of the head whose 
circumferences are in most cases the maximum circumferences engaging 
in the pelvis are the suboccipito-bregmatic and the suboccipito-frontal. 
The occipito-frontal it is well to note, yet the latter is of little practical 
importance. These cross-sections extend through the corresponding 
diameters respectively. Their circumferences are as follows : 

Suboccipito-bregmatic circumference 33 cm. 13 inches. 

Suboccipito-frontal " 35 " 13% " 

Occipito-frontal " 34.5 " 13% " 

Moulding. Comparing the dimensions of the fcetal head with one 
another it will be seen that the head is an irregular cylindrical mass, the 
long axis of which is 14 cm., 5 J inches, and the transverse 9.5 cm., 3f 
inches. 

Normally the long axis of the cylinder lies nearly in relation with the 
axis of the birth-canal; the engaging diameters of the average head, 
those which lie across the parturient tract, differ little from those of the 
maternal pelvis. The value of the suboccipito-bregmatic circumference 
is the same as that of the pelvic outlet. 

In most births the cylindrical form of the cephalic mass becomes still 
more pronounced during labor, owing to the moulding which takes place 
from the pressure effects of the birth-canal. The elongation of the 



180 PHYSIOLOQ ? OF LABOR. 

cylinder is further increased by the formation upon the presenting pari 
of the caput Buocedaneum, to be described in another chapter. 

The principal diameters of the head arc all affected In greater or Less 
degree by the moulding of the head in its passage through the birth- 
canal. The biparietal is reduced in ordinary labor by about 0.6 cm., 
\ inch. The Buboccipito-bregmatic and the suboccipito-frontal are cor- 
respondingly shortened. The occipito-mental is Lengthened. In a word, 
the engaging diameters are compressed, and there is a corresponding 
elongation ol the diameter which is in relation with the axis of the 
parturient tract. The moulding is chiefly the result of overlapping of 
the cranial bones. It may he noted in passing that the measurements 
of the head for record should he taken after it has resumed its normal 
shape. 

The head undergoes in slight degree a total reduction in volume dur- 
ing its passage through the pelvis, owing to the fact that a portion of 
the cerebro-spinal fluid aud of the contents of the intracranial blood- 
vessels is forced out of the cranial cavity by compression. 

The plasticity of the head is obviously an essential factor in the par- 
turient process. The hardness of the cranial vault is, therefore, always 
to be taken into account in estimating the prognosis of labor. 

The Trunk. The trunk diameters are small, and moreover are so com- 
pressible as to render them of relatively little importance in the mech- 
anism of labor. The longest of the trunk diameters is the bisacromial. 
Its length is 12 cm., 4f inches; but it is reducible to the extent of at 
least 2 or 3 cm. The antero-posterior or sterno-dorsal diameter at the 
level of the shoulders is 8.5 cm., 3f inches, and is reducible to 8 cm. 
The average chest measure (circumference) is 12 \ inches. The bitro- 
chanteric diameter is 9 cm., 3 J inches. The antero-posterior diameter 
at the breech, the sacro-pubic, is 5.5 cm., 2 J- inches. With the super- 
added thickness of the thighs flexed upon the abdomen, the antero- 
posterior diameter is nearly doubled. 

Length and Weight of the Mature Foetus. The length of the child at 
term is usually between 46 and 51 cm., 18 and 20 inches. The average 
weight is 3150 to 3290 grammes, 7 to 7 J pounds, males weighing more 
than females, and first, as a rule, less than subsequent births. The usual 
birth-weight may be said to vary from 2700 to 5400 grammes, 6 to 11 
or 12 pounds. In very rare instances the latter limit is exceeded, and 
phenomenal weights of more than 9000 grammes, 20 pounds, have been 
recorded. There is usually a progressive gain in the weight of the 
children in successive pregnancies of the same mother till the fourth 
or fifth. 

Mobility of the Foetal Head Upon the Spinal Column. The movements of 
extension or flexion and of rotation of the head upon the trunk sustain 
important relations to the mechanism of labor, as will be seen in connec- 
tion with the discussion of that subject. These movements are favored 
by the laxity of the joints in the cervical portion of the spinal column. 
The limit of safe rotation of the head upon the trunk is generally 
believed to be 90 degrees on either side. Tarnier, however, asserts that 
the rotation may be continued without injury to the cord or to the liga- 
ments till the face looks directly backward. The torsion is not confined 



THE MECHANICAL ELEMENTS OF LABOR. 181 

to a single point in the spinal column, but is distributed along the upper 
portion of its length. 

PRESENTATION, POSITION, AND POSTURE OF THE FCETUS. 

Presentation is, in general terms, the relation of the long axis of the 
foetal ovoid to the uterine axis. Under this definition we have two vari- 
eties of presentation : longitudinal and transverse. 

Longitudinal Presentation is that in which the long axis of the 
foetal ovoid corresponds with the axis of the uterus, either the cephalic 
or the pelvic extremity offering at the brim of the pelvis. 

Transverse Presentation is that in which the long axis of the 
foetal mass lies across the long axis of the uterus. Except very rarely, 
however, its direction is not transverse but oblique. In this presenta- 
tion any part of the foetus, except the cephalic or the podalic extremity, 
may offer primarily at the pelvic inlet. 

As commonly employed the term presentation refers to the part of the 
foetus which presents at the pelvic brim. Thus we have cephalic and 
breech as sub varieties of longitudinal presentation; vertex, face, and brow 
as sub varieties of cephalic presentation ; breech and foot as sub varieties of 
pelvic presentation; shoulder, arm, and hand as sub varieties of transverse 
presentation. Since in transverse presentation the shoulder ultimately 
becomes the presenting part, transverse is also known as shoulder pre- 
sentation. 

The term presenting part is used to denote the part of the foetal ovoid 
which offers to the examining finger. It is, therefore, synonymous with 
presentation in the sense last referred to. 

The varieties and subvarieties of presentation may be summarized as 
follows : 

Presentations. 

1. Longitudinal. 

A. Cephalic, (a) Vertex; (6) face; (c) brow. 

B. Breech, (a) Breech; (6) knee; (c) foot. 

2. Transervse. 

(a) Shoulder; (b) arm; (c) hand. 

Relative Frequency of the Different Presentations. The vertex presents 
in about 97 per cent, of all labors at term. Spiegelberg found cephalic 
presentations in 97 per cent, of the children in 97,871 labors; Lepage 
in 97.32 per cent, of 3032 primiparse, and in 97.24 per cent, of 3598 
multiparse, at the Cliuique Baudelocque. The breech presents in about 
1.6 per cent, of all labors; transverse presentation occurs in 0.5 per 
cent. The preponderance of vertex presentations is due mainly to adap- 
tation of the foetal ovoid to the shape of the uterus, and in some degree 
to gravity, the cephalic being the heavier extremity of the foetus. 

Position. Position is the relation of the presenting part to the quad- 
rants of the pelvic brim, the quadrants being those into which the brim 
is divided by the antero-posterior and the transverse diameters. For 
each presentation there are four positions. They are named according 
to the particular quadrant confronted by the presenting part, sometimes 
from some anatomical point at the brim selected for its prominence. 



182 PHYSIOLOGY OF LABOR. 

In vertex, face, and breech presentations the long diameter of the 
presenting part engages in one of the oblique diameters of the pelvic 
inlet In vertex presentation the occiput Looks to the right or to the 

left anterior or to the right «>r left posterior quadrant. When the occi- 
put confronts the left anterior quadrant, the position is left occipito- 
anterior; if it face- the right anterior quadrant, the position is right 
occipitoanterior, and SO on. The positions are sometimes spoken of as 
first, second, third, and fourth, the left occipitoanterior being the first, 
ami the others following in order from left to right around the pelvic 
brim. Face positions are named in similar manner according to the 
direction of the chin — left mento-anterior, etc.; breech positions, accord- 
ing to the direction of the sacrum — left sacro-anterior, etc.; shoulder 
positions, according to the direction of the scapula — left scapulo- 
anterior, etc. 

Vertex Positions. 



Left occipito-anterior. L. O. A. 
Right occipito-anterior. R. O. A. 
Right occipito-posterior. R. O. P. 
Left occipito-posterior. L. O. P. 



The relative frequency of the different vertex positions may be roughly 
stated at 75, 20, 4, and 1 per cent, respectively. 

Face Positions. 

Left men to-anterior. L. M. A. 
Right mento-anterior. R. M. A. 
Right mento-posterior. R. M. P. 
Left mento-posterior. L. M. P. 

Breech Positions. 

Left sacro-anterior. L. S. A. 
Right sacro-anterior. R. S. A. 
Right sacro-posterior. R. S. P. 
Left sacro-posterior. L. S. P. 

Transverse or Shoulder Positions. 

Left scapuloanterior. L. Sc. A. 
Right scapulo-anterior. R. Sc. A. 
Right scapulo-posterior. R. Sc. P. 
Left scapulo-posterior. L. Sc. P. 



THE MECHANICAL ELEMENTS OF LABOR. 

Fig. 162. 



18a 




Vertex. Left occipitoanterior position. (Ribemont-Dessaignes and Lepage.) 

Fig. 163. 




Vertex. Right occipitoanterior position. (Ribemont-Dessaignes and Lepage.) 



L84 



PHT8I0L0Q ) OF LABOR 
FlO. LM. 




Vertex. Right occipito-posterior position. (Ribemont-Dessaignes and Lepage.) 

Fig. 165. 




Vertex. Left occipito-posterior position. (Ribemont-Dessaignes and Lepage.) 



THE MECHANICAL ELEMENTS OF LABOR. 

Fig. 166. 



185 




Face. Left mentoanterior position. (Farabeuf and Varnier. 
Fig. 167. 
f 




Face. Right mento-anterior position. (Farabeuf and Varnier. 



186 



PHYSIOLOQ ) OF LABOR. 

Fto. 168. 




Face. Right mento-posterior position. (FARABEUFand Varnier.) 
Fig. 169. 




Face. Left mento-posterior position. (Farabeuf and Varnier.) 



THE MECHANICAL ELEMENTS OF LABOR. 
Fig. 170. 



187 




Breech Left sacroanterior position. (Farabeuf and Varnier.) 
Fig. 171. 




Breech. Right sacro-anterior position. (Farabeuf and Varnier.) 



188 



PHYSIOLOQ V OF LABOR 
Fig, 172. 




Breech. Right sacroposterior position. (Farabetjf and Vabnier.) 
Fig. 173. 




Breech. Left sacro-posterior position. (Farabeuf and Varnier.) 



THE MECHANICAL ELEMENTS OF LABOR. 

Fig. 174. 



189 




Shoulder. Left scapuloanterior position. (Fababeuf and Varnieb.) 
Fig. 175. 




Shoulder. Right scapuloanterior position. (Fababeuf and Varnieb.) 



1 ( J0 



PHY8I0L0Q )' OF LABOR. 



I [G L7I 




Shoulder. Right scapulo-posterior position. (Farabeuf and Varnier.) 



Fig. 177. 




Shoulder. Left scapulo-posterior position. (Farabeuf and Varnier.) 



THE MECHANICAL ELEMENTS OF LABOR. 191 

Posture, or the attitude of the foetus, is the relation of the foetal mem- 
bers to one another. The normal posture of the foetus during pregnancy 
and parturition is one of flexion. The head is flexed, the arms are 
folded on the chest, the legs are flexed upon the thighs, and the thighs 
on the abdomen. The back is arched, and the foetal mass presents an 
ovoid shape. The foetal posture is the result partly of the primitive form 
of the embryo, mainly of the uterine pressure forces. As an element in 
the labor, posture is most important as relates to the head. 



.' 



CHAPTER VIII. 

I 'HE MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 

Definition of Normal Labor. The term eutocia is applied to labors which 
terminate without artificial aid and without injury to mother or child. 
All such labors an 4 in a sense natural or normal, and in most obstetric 
text-books are bo classified. In the present work the term normal labor 
will be restricted to labors in which there is no element of dystocia, those, 
in other words, in which all the mechanical elements are normal and 
which are not rendered dangerous to mother or child by complications 
independent of the mechanism. Under this definition only uncom- 
plicated labors in which the vertex presents in anterior position will he 
classed as normal. 

Stages of Labor. 

Labor is divided into three stages: 

The first stage, or stage of dilatation, ends with the full dilatation of 
the utero-cervical zone. 

The second stage, or stage of expulsion, ends with the birth of the child. 

The third stage, or placental stage, ends with the expulsion of the 
placenta and membranes and complete retraction of the uterus. 

The Duration of Normal Labor. 

It is difficult to determine clinically the precise time when labor begins. 
For practical purposes, it is sufficient to date the onset of the parturient 
process from the time the woman is conscious of regularly recurring 
uterine contractions. In many instances, however, occasional pains are 
felt for days or weeks before labor is actively established. On the other 
hand, considerable dilatation is very frequently accomplished without 
pain. Sometimes the labor may wholly cease for a time after it has 
continued for several hours. 

The time occupied by the process of dilatation varies greatly in dif- 
ferent cases. Other things being equal, it is shorter in multipara? than 
in primipara?, since the soft parts offer less resistance after the first 
childbirth. It is especially prolonged in aged primipara?, owing to 
excessive rigidity of the cervix uteri and of the pelvic floor in that 
class of parturients. 

In typical normal conditions the average period from the beginning 
of active labor to complete canalization of the utero-cervical zone may 
be fairly stated at from ten to fourteen hours for primiparous and from 
six to eight hours for multiparous women. 

The average length of the second stage is approximately two hours in 
the primipara and one hour in the multipara. 

The expulsion of the placenta usuallv takes place within a period 
(192) 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 193 

varying from a few minutes to two hours after the birth of the child. 
The average period is about twenty minutes. 

Causes of the Onset of Labor. 

A process like labor, involving so extensive coordinate muscular action, 
implies the existence in the nervous system of controlling motor centres 
for the regulation of the uterine contractions. Though it has been suffi- 
ciently established that there is such a centre in the medulla, from which 
impressions travel, probably down the cord and through the sacral 
plexus to the uterus, rhythmical contractions are not solely dependent 
on this centre, as is proved by the fact that contractions go on after 
connection with the medulla has been severed. For example, rhythmical 
contractions have been known to take place in the horn of a uterus which 
had been removed while labor was going on. In addition to the nerve 
centre in the medulla we have the cervical ganglion, an extensive plexus 
of nervous matter lying on the posterior vaginal fornix and intimately 
connected with the uterus by numerous filaments. It is formed by the 
union of nerve cords from the hypogastric plexus, and it receives fila- 
ments from the second, third, and fourth sacral nerves. Whether the 
motor impulses travel by the cord or pass by the path of the sympa- 
thetic trunk is a question that cannot be finally answered at the present 
time. Lusk and others have reported cases of successful labor in 
women having paralysis of the lower extremities, retention of urine, 
and incontinence of feces. Observations of this character would seem to 
show that the cord is not the only route by which impulses are trans- 
mitted. Charpentier says the influence of the spinal cord over uterine 
contractions cannot be denied, for in women who have paralysis, uterine 
contractions, if less painful, are also very feeble, and if a few such had 
easy deliveries, yet in the majority labor is tedious from feeble uterine 
contractions. Besides the centres just mentioned, Dembo found collec- 
tions of ganglionic cells between the peritoneal and the muscular walls 
of the uterus and groups of cells lying in the anterior vaginal wall which 
he believes to be uterine motor centres. 

Thus there are three motor centres which may give rise to contrac- 
tions of the uterus — a centre in the medulla, the cervical ganglion, 
and a collection of ganglia in the anterior walls of the vagina and in 
the walls of the uterus. Of the relative importance of these centres we 
have no definite knowledge. 

A great many theories have been advanced to account for the onset of 
labor, but none of them are entirely satisfactory, since none apply to all 
cases. All we can say at present is that labor is not the result of any 
one, but is due to the concurrent operation of a number of causes. These 
act by inducing uterine contractions, or perhaps it would be better to 
say by increasing the painless rhythmic contractions which are present 
in marked degree throughout the entire period of pregnancy. Among 
the probable causes of the active uterine contractions of labor the most 
important are the following: 

1. Loosening attachment of the ovum, converting it into a foreign 
body. 

2. Excess of carbon dioxide in the blood. 

13 



[94 PHYSIOLOGY OF LABOR, 

3. Distention of the uterus l>y the growing ovum. 
1. Mental impressions. 

1. Loosening Attachment of the Ovum. Separation of the deoidua rem 
begins with the first active oootractione of the uterus. The separation 
may be the result of a number of contributing factors; for example, 
fatty degeneration of the deoidua has been observed in the latter part of 
pregnancy ; but this is not constantly found. Simpson claimed that it 
occurred in the fourth month of pregnancy. 

The deoidua vera is divided into two parts. One part consists of an 
outer, dense, membranous layer of large cells resembling pavement epithe- 
lium ; the other part, of a layer of much looser texture in which are found 
the large decidual glands. It is in this spongy layer that the separation 
of the deoidua takes place. In this layer toward the end of pregnancy 
the trabecules enclosing the spaces of the network have been observed 
to decrease in size from jfa of an inch to y^Vo" of an inch. The layer 
seems to shrivel and thus to permit easy separation. The occurrence 
of hemorrhages, the result of the compression and tearing caused by the 
violent uterine action, also tends to detach the ovum from the walls of 
the uterus, aud may act to intensify the pains already established. This 
separation of the decidua from the uterine wall makes the ovum in part 
a foreign body, and this explains the continuance of the expulsive efforts. 

2. Excess of Carbon Dioxide in the Blood. Brown-S6quard has shown 
that excess of carbon dioxide in the blood of pregnant animals will 
bring on uterine contractions. This effect may be produced directly 
or through the uterine motor centre. As the foetus grows, it demands 
more nutriment, and there must be a corresponding increase of the 
products of tissue waste, including carbon dioxide. The presence of 
carbon dioxide in the blood of the placenta is accounted for in several 
ways, but many of the explanations agree in this, that it is the result 
of some interference with the passage of the blood through the pla- 
centa. Leopold and Ruge believe it to be due to the formation of 
thrombi in the placenta. Friedliinder explains the formation of blood 
coagula in this organ by the penetration into the uterine sinuses of the 
cells that form in the serotina about the eighth month. Another ex- 
planation of the increase of the carbon dioxide is based on the fact that 
the trabecular of the sinuses are observed to decrease until, at the end 
of pregnancy, they are about one-fifth their former size. This may be 
the result of cell infiltration of the walls and consequent contraction. 
When the venous blood has accumulated to a certain amount the con- 
tained carbon dioxide stimulates the uterine contractions, and labor is 
established. 

3. Distention of the Uterus. The growth of the gravid uterus is a 
result in part of development of the uterine muscularis, in part of dis- 
tention of the uterine parietes. There is not only hypertrophy and hyper- 
plasia, but as well, it is assumed, a rearrangement of the muscular fibres, 
so that, instead of lying side by side, they are disposed nearly end to 
end. When the limit is reached and growth and extension can go on 
no further, then labor begins. 

Power likened the evacuation of the uterus to the emptying of viscera 
such as the bladder and the rectum. These permit distention to a certain 
extent and then expel their contents. 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 195 

4. Mental Impressions. It is only necessary to mention the effect of 
great grief as an etiological factor in abortion to call to mind how im- 
portant a part the emotions may play in inducing labor. But such 
agencies as these and slight muscular strains, jars, and falls happening 
at the close of gestation, and the descent of the foetus low in the pelvis, 
due to yielding of the cervix, cannot be viewed as essential causes of the 
onset of labor. The establishment of labor is often wholly independent 
of such influences. 

In the existing state of our knowledge it is impossible to say which 
of the many possible causes are most active in bringing about the final 
result. 

The Clinical Phenomena of Beginning La bob. 

The more important phenomena of labor are those which pertain to 
the uterus. These will next be considered. 

Labor Pains. Contractions of the uterus occurring during labor are 
known in all languages by the word which expresses pain. Labors un- 
attended with pain have been recorded, but they are exceedingly rare. It is 
also stated that patients have been delivered in a condition of hypnotic 
sleep, but such experiences are among the rarer curiosities of obstetric 
practice. The cause of the painful sensations in the early part of labor 
is the distention of the cervix, and in the latter part the suffering is 
due to stretching of the vagina and vulva and to compression of the 
nerve-trunks in the pelvis. 

Bearing in mind that the uterine musculature is a collection of non- 
striated muscular fibres, it may be expected to manifest the same kind 
of activity that is observed in this variety of muscular tissue in other 
parts of the body. 

The contractions are involuntary. The patient cannot initiate them 
nor can she stop them when they have begun, although in the stage of 
expulsion she can assist them by voluntarily bringing the abdominal 
muscles into play. Notwithstanding the automatic character of the 
uterine contractions, mental impressions may affect them in a marked 
degree; for example, the arrival of the physician may retard, and even 
for a short time arrest, the labor. The pains are liable to be inhibited, 
too, by the reflex effect of a full bladder or rectum. 

The pains are intermittent, and the interval between them varies with 
the stage of progress. The intervals of repose grow shorter as the labor 
progresses, until finally, at the end of the second stage, the expulsive 
efforts are almost continuous. The intermittent character of the pains 
is essential to the safety of the foetus. During the height of a uterine 
contraction the placental circulation is almost wholly interrupted, and 
the foetus, moreover, suffers powerful compression. Under persistent 
uterine contraction it would soon perish. 

The contractions are peristaltic, proceeding from one extremity of the 
uterus to the other. The direction of this contraction wave is from 
fundus to cervix. In some of the lower animals contractions have been 
observed to pass from cervix to fundus, but such phenomena are doubt- 
less exceptional and abnormal. The wave is said to last from one-third 
to two-thirds the length of the labor pain. Assuming that the average 



L96 



PHYSIOLOGY OF LABOR. 



duration of a pain is < 

twenty to forty seconds 



minute, the peristaltic wave would last from 



The Mechanism op Dilatation. 

Upper and Lower Uterine Segments. The gravid, Like the non-gravid 
uterus, presents two general divisions, the body and the cervix. The 

body of the parturient uterus, however, resolves itself into two part-, 
designated respectively the upper and lower uterine segment. The 
plane which separates the two segments lies nearly at the level of the 
utero-vesica] fold of peritoneum. This plane represents the level at 
which the conical lower portion of the cavity begins to he smaller than 
the greatest sectional plane of the foetal head which must pass through 
it. The lower uterine segment, therefore, comprises all that portion of 
the body of the uterus which, together with the cervix, must undergo 
dilatation preparatory to the expulsion of the foetus. The upper uterine 
segment includes approximately the upper two-thirds of the entire 
length of the uterus; the lower segment and the cervix, which are of 
nearly equal lengths at the beginning of labor, constitute the remaining 
thirds Fig. 178. 



Fig. 17£ 



VI mn m 




CR. Contraction ring, or retraction ring, at onset of labor. 

(SCHROEDER.) 



Os internum, oe. Os externum. 



Uterine Retraction. During labor the expellent force must obviously 
be supplied by the contractions of the upper uterine segment. The 
lower segment is concerned in dilatation, and after dilatation is fully 
established it has become entirely passive. The dilatation which takes 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 197 

place in the cervix and the lower uterine segment as the upper segment 
contracts is a phenomenon somewhat comparable to what occurs in other 
hollow viscera during the expulsion of their contents. It is in part a 
relaxation and in part the result of distention. 




Retraction ring at end of first stage of labor. Lower birth canal consists of the lower uterine 

segment and the cervix. (Schroeder.) 

oe. Os externum, oi. Internum. CE. Contraction or retraction ring. 

After labor is established the musculature of the upper uterine seg- 
ment becomes thickened, and that of the lower segment as it dilates is 
correspondingly thinned. The line of demarcation between the thickened 
upper and the thinned lower segment presents a ridge which can often 
be made out on palpation over the abdomen during labor. Fig. 179. 

This ridge is called the ring of Bandl, from the name of the authority 
who first described it. It is also known as the contraction or the 
retraction ring. The latter is, perhaps, the preferable term. The situ- 
ation of the retraction -ring, which at the onset of labor is below the 
pelvic brim, rises higher as the pains go on, and in abnormally long or 
obstructed labors may reach nearly the level of the navel. The term 
retraction applies to the process by which the thickening takes place in 
the upper segment. It is due mainly, if not wholly, to persistent short- 
ening and thickening of the muscular fibres. While the shortening of 
the muscular fibres which occurs during the uterine contractions is 
followed by elongation in the intervals, the primal length is not fully 
restored. It is commonly taught that retraction is due in part also to 
a rearrangement of the muscular fibres. Fibres, it is assumed, which 



198 PHYSIOLOGY OF LABOR 

at the beginning of labor lie nearly end-to-end, in course of retraction, 

OOme to lie nearly side l>v Bide. The retraction of the upper segment 

of the uterus increases as the volume of its content- is diminished. The 

retraction, in other words, progresses in proportion to the prOgTC 

the birth and the upward movement of the retraction-ring. 

Dilatation of the Cervix. In the dilatation of the cervix three agencies 
are concerned: 

1. Softening of the cervical tissues. 

2. The hydrostatic pressure of the bag of waters. 

8. The contraction of the longitudinal fibres of the upper uterine 
segment, 

1. Progressive softening of the cervix, commencing below and 
extending upward, is normally present from the early months of preg- 
nancy, and is a valuable sign of this condition. Contractions of the 
uterus, by interfering with the return circulation, cause over-distention 
of the cervical veins and lymphatics, and there is an infiltration of the 
tissues with serous exudate; at the onset of labor the infiltration and 
softening increase rapidly. 

The yielding of the cervix in the first stage of labor is doubtless in 
part a physiological relaxation analogous to that which takes place in 
sphincter muscles. 

2. Hydrostatic Pressure of the Bag of Waters. The second 
agency in securing dilatation — pressure from the bag of waters — is a 
very important one. Its value is most clearly brought to our attention 
when we have lost it. If, by mischance, early rupture of the mem- 
branes has occurred, and the waters have drained away, the labor is 
termed a dry labor. Such labors are proverbially liable to be of long 
duration and prejudicial to mother and child. 

During a uterine contraction, as the cervix opens, the lower portions 
of the membranes, loosened from their attachments by the first active 
uterine contractions, insinuate themselves into the opening. Since the 
fluid within the membranes transmits the force of the uterine contraction 
equally in all directions, the bag of waters is distended laterally as well 
as downward, exerting an expansive action directly upon the walls of 
the cervix. The lateral expanding force acts in the radii of the resisting 
ring. Other things being equal, the hydrostatic pressure increases with 
the area of the surface on which it acts. The dilating force becomes 
greater, therefore, in proportion as the dilatation progresses. Fig. 180. 

With premature rupture of the membranee we lose the efficient 
hydrostatic wedge, and have in its place the head. This substitutes a 
body almost unyielding in its nature for the water-bag. The former 
is inferior in dilating power to the equable hydrostatic pressure of the 
bag of waters, but moulding and the caput succedaneum, yet to be 
described, add somewhat to the sharpness of the dilating wedge. They 
compensate in some degree for the loss of the hydrostatic pressure of the 
sac of waters. 

3. Action of the Longitudinal Muscular Fibres of the 
Uterus. While the membranes are unruptured the contents of the 
uterus are practically incompressible. We may imagine a uterus con- 
taining an absolutely incompressible body of a similar shape to the ovum. 
It is obvious that the pull of the contracting longitudinal muscular fibres 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 199 



of the upper uterine segment will act to drag the lower segment and 
cervix upward over the contained body. The oblique muscular bundles 
act in some degree with like effect. It must be remembered, too, that 
the circular bundles are not so strong in the cervix as in the fundus. 
The muscular structure of the lower segment is thinner and weaker than 
that of the upper segment. 

Fig. 180. 




Bag of waters shortly before complete dilatation of os externum , 
Ribemont-Dessaignes and Lepage.) 



(Modified from 



Another explanation of the dilating mechanism which has been offered 
is the following: When a wave of contraction passes from one end of 
the uterus to the other, it must pass through the length of the longi- 
tudinal fibres and across the circular fibres. It is suggested that the con- 
traction wave traverses the longitudinal fibres more rapidly than it affects 
the circular fibres. If this is true, the wave passing through the longi- 
tudinal fibres would reach the cervix before that affecting the circular 
fibres, and would draw the cervix over the presenting part while the 
circular fibres of the lower segment are at rest. 

The Cervical Rings. The first effects of the dilating force are observed 
at the internal os. This expands with the pains, and for a time con- 
tracts again in the intervals. As the dilatation progresses the os in- 
ternum becomes permanently relaxed. A digital examination at this 
time reveals two distinct resisting rings, one at the external and one at 
the internal end of the cervical canal. The canal itself preserves a 
pronounced fusiform shape. Later, the os internum becomes perma- 
nently obliterated, having merged into the lower uterine segment. The 
ovum from this time rests upon the external ring or the os externum. 
This is gradually expanded as the labor goes on, till finally the walls of 
the dilated utero-cervical zone and those of the vagina form one continu- 
ous canal, with a barely perceptible interruption at the external ring of 
the cervix uteri. 



200 PHT8I0L0Q V OF LABOR, 

Retraction of the Pubic Segment of the Pelvic Floor. Toward the close of 
the first stage and during the earlier pari of the second, as the cervix 
is drawn upward over the head, the Madder i- lifted partly above the 
pubic bone by the traction of the Longitudinal muscular fibres of the 
uterus. The bladder is thus in some measure protected from injury by 
the pressure of the head as it traverses the pelvic canal. 

The Clinical Phenomena of the First Stage. 

The Pains. The patient realizes that she is in labor when she begins 
to suiter regularly recurring pains in the back. From this region the 
pains may radiate around to the front and, perhaps, are felt running 
down the lower limbs. 

The initial labor pains most frequently come on in the early part of 
the night. They at first recur at intervals of about thirty minutes, but 
as the labor goes on the intervals become progressively shorter. 

The pains differ little in character from the so-called false pains fre- 
quently experienced during the later weeks of pregnancy, but they are 
distinguished by a more or less rhythmical recurrence and by growing 
strength and frequency. 

The painful character of the uterine contractions of labor is probably 
due in great part to the stretching of the cervix. The pains are sharp 
and " nagging." The patient walks restlessly about the room, sits in a 
chair, or at times takes to the bed. If she is on her feet when a con- 
traction begins, she bends over a chair or other object near at hand. 
Her face during the pains is congested, owing to fixation of the respira- 
tory muscles. Reflex vomiting is not infrequent as the dilatation becomes 
nearly complete. Its occurrence may usually be taken as evidence that 
the first stage of labor is well advanced. 

The uterine contraction of labor presents three stages — a period of 
increase, a period of acme, and a period of decrease. The stage of acme 
lasts longer than the other stages, and the increase is longer than the 
decrease. The length of the acme differs somewhat at different stages 
of labor. 

The force of the contraction has been estimated by different methods, 
none of which is entirely satisfactory. Attempts have been made to 
estimate the stress necessary to rupture the membranes, and, by placing a 
bag of water in the uterus in front of the advancing head, to determine 
how much tension is sustained by the contents of the bag during 
a pain. According to Duncan and Poppel, the membranes rupture 
under a pressure ranging between four and thirty-seven and a half 
pounds. Schatz, by the aid of a manometer, estimated the resistance 
overcome by the advancing head to be between seventeen and fifty-five 
pounds. We have as yet, however, no reliable means of determining 
the force exerted in expelling the child. 

The degree of pain is variable. The pains of dilatation are often not 
so well borne as those that come later, because the parturient is impatient 
of suffering which seemingly results in no progress. The pain caused 
by the passage of the head over the pelvic floor, if not relieved by an 
anaesthetic, is usually the most intense. 

The Show. By expansion of the cervix and the lower uterine segment, 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 201 

the membranes in the lower part of the uterus are separated from the 
uterine wall, causing a slight discharge of blood known as the show. 

The cervical and the vaginal secretions become more profuse as labor 
is established. They serve as a lubricant to the passages in preparation 
for the expulsion of the foetus. 

The irritability of the bladder and the rectum already established by the 
lightening, is increased when active pains begin. Urinary and fecal 
evacuations occur more frequently than before. 

The cervix becomes thin and sharply defined during the pains. In 
multipara the lower part of the cervix is more patulous, and offers less 
resistance to the advancing bag of membranes than in primiparae. 

The Pulse. The maternal pulse becomes more rapid during a pain; 
the heart-tones of the foetus are less distinctly audible, and the pulse-rate 
is slower than in the intervals. The fall in the foetal pulse-rate is due 
to increased vascular tension caused by the compression to which the 
foetal mass is subjected during a uterine contraction. 

Rupture of the Bag of Waters. When the cervix has become well 
dilated, rupture of the membranes may occur. It may take place at an 
earlier period, or may not happen till the end of the stage of expulsion. 
Very rarely a full-term child may be born with the membranes unbroken. 

Rupture of the bag of waters is announced by a gush of water from 
the vagina. The quantity of liquor amnii expelled will depend on the 
extent to which the lower uterine segment is occluded by the presenting 
part. It is not always safe to rely on the patient's statement that the 
membranes have ruptured. She may be misled by leakage of urine 
from the bladder. If the discharge is due to rupture of the membranes 
there is usually more of it between than during the pains, since the head 
then recedes and allows the waters to escape. Sometimes an accumula- 
tion of fluid has taken place between the amnion and chorion, and this 
may escape by rupture of the chorion, the amnion still remaining intact. 
It is claimed that amnial liquor may transude through the unbroken 
membranes. 

Emotional Influences. The progress of the labor in this stage is easily 
influenced by emotional causes. The presence of a strange face or the 
narration of the horrors of previous cases by friends or by the nurse may 
stop the pains for a long time. After the membranes give way the uterus 
retracts as the waters escape, and the pains are resumed with new vigor. 

The bearing of the patient differs greatly in different women; some 
apparently suffer very little, and others complain bitterly of pains. 

The Mechanism of Expulsion. 

The " mechanism of the second stage of labor " concerns especially 
the movements which the foetal head and the trunk undergo in course of 
their transit through the birth-canal. Since the head-diameters are 
larger and less compressible than are those of the trunk, the mechanism 
is most important as relates to the head. 

1. The head movements are : Descent, flexion, rotation, extension, 
restitution, external rotation. 

Descent. During the first stage of labor, as has been seen, the force 
of the uterine contractions is expended in dilating the utero-cervical 



202 



l'HYSIOLOGY OF LABOR. 



Fig. 181. 



zone. At the beginning of labor, if the membranes are intact, the 
intra-aterine pressure developed by a uterine contraction is, in accord- 
ance with the familiar law of hydrostatics, brought to hear upon the 
foetus equally in all directions. After partial dilatation of the cervix 

and the formation of the bag of waters the head sinks into and partially 
occlude- the lower uterine segment. Under the pressure developed in 
the hind waters during a uterine contraction the head advances as tin,' sac 
of forewaters protrudes. After the membranes rupture the head descends 
with a moving force which is measured by the propelling power less the 
resistance opposed by the birth-canal. 

So long as the waters have not all escaped, the expellent force is trans- 
mitted to the head, in part, sometimes wholly, through the liquor amnii. 
After the waters have drained away the foetal parts are consolidated in 
a compact mass by the grasp of the uterus, and, the fundus contracting 
directly upon the breech, the propelling force is transmitted in great 
measure through the entire foetal ellipse. The lateral compression 
exerted by the uterine contractions acts to steady the foetal mass and 
adds also somewhat to the extruding force. 

Flexion. Flexion is in part primary, being the normal posture of the 
foetus in utero. It is increased when the head begins to encounter the 

resistance of the lower uterine segment, 
and becomes complete after engagement 
in the bony pelvis. The mechanism is 
as follows: The head is so attached to 
the trunk that its sincipital is longer than 
its occipital pole. The head, in other 
words, corresponds to a lever of unequal 
arms, the occipito-atlantoid articulation 
being the pivotal point and the sincipital 
arm the longer arm of the lever. Fig. 181. 
When the head begins to encounter the re- 
sistance of the birth-canal this resistance, 
even though equal at the two poles, must 
act with greater effect on the long arm of 
the lever. This advantage in normal con- 
ditions is increased by the primary flexion. 
The chin, therefore, dips toward the ster- 
num. The flexion is increased as the op- 
posing forces increase, and becomes com- 
plete when the head meets the resistance 
of the bony walls of the pelvis. 

Another factor in bringing about the 
flexion of the head is to be found in the 
tendency of the cephalic ellipsoid to adapt 
itself to the shape of the canal through 
illustrating the different lengths of which it descends. Under the pressure 
the frontal arm, fb, and the occipital of the pelvic walls the long axis naturally 

arm BO of the lever presented by the fallg j t relation with the axis f the 
foetal head. . 

birth-canal. 
The advantage of flexion is obvious. It brings the smallest, or sub- 
occipito-bregmatic, circumference of the head in relation with the girdle 
of resistance in place of the larger occipito-frontal circumference. 




MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 203 

As has been stated, the head enters the brim fully flexed, or it soon 
becomes so under normal circumstances; thus all motion in an antero- 
posterior direction is checked, but some degree of lateral mobility still 
remains. A great deal of discussion has arisen with reference to the 
question whether the head inclines laterally to one side or the other 
during its passage through the brim. Naegele and Dubois hold that 
the anterior parietal bone dips deeper in the pelvis than the poste- 
rior, bringing the sagittal suture nearer to the promontory than to the 
symphysis. This lateral obliquity of the head is termed asynclitism. 
When the head descends with its planes parallel to those of the pelvis 
the descent is said to be synclitic. Kuneke and most other authorities 
believe that synclitism is preserved till delivery takes place. In labor in 
deformed pelves the obliquity of Naegele is present in some degree. 

Rotation. When the head reaches the pelvic floor the long diameter 
of the head which passed the brim in a direction parallel with the oblique 
diameter of the pelvis begins to turn till at the moment of expulsion it 
is nearly parallel with the antero-posterior diameter of the pelvis, the 
occiput normally swinging to the front. 

The chief agency in bringing about the rotation of the head as it tra- 
verses the pelvis is the action of the pelvic floor. The floor of the pelvis 
may be considered as made up of two lateral halves, each of which slopes 
downward, inward, and forward. That pole of the foetal head which 
lands first on one lateral half of the floor glides downward, inward, and 
forward, and emerges from the outlet beneath the pubic arch. When the 
head is normally flexed the occipital pole first reaches the floor of the pelvis, 
and, as it descends, is rotated inward to escape under the arch of the pubes. 

It will be noted that flexion is a prerequisite to rotation. It is only 
when the occipital pole of the head dips lower in the pelvis than the sin- 
cipital that anterior rotation of the occiput is likely to prevail. Should the 
sinciput reach the pelvic floor at the same time as the occiput the former 
may be rotated forward under the symphysis, the latter going backward 
into the hollow of the sacrum. 

The influence of the planes or grooves of the bony pelvis, on which 
stress is laid by certain obstetric writers, is of secondary importance in 
effecting rotation of the head. That the action of the pelvic floor is 
the principal agency in causing rotation would seem to be sufficiently 
established by the experiment of Dubois. Dubois showed that when 
the head of a foetus is pushed through the pelvis of a woman who had 
died before or immediately after delivery, no matter in what position 
we place the occiput, if it strikes the pelvic floor in advance of the 
sinciput, it will turn forward, provided the floor has not been injured by 
rupture or overstretching. The repetition of the experiment will, if 
too often repeated, overstretch the floor and then rotation will fail. 

Edgar, of New York, screwed a swivel into the head of a foetus half 
an inch behind the small fontanelle. Attaching a cord to the ring of 
the swivel, he repeatedly dragged the head through the pelvis of a woman 
dead after recent delivery. The occiput invariably rotated to the front, 
even when the head entered the pelvis in occipito-posterior position, so 
long as the pelvic floor retained its integrity. When the tonicity of the 
floor became impaired by overstretching, the head traversed the pelvis 
in very nearly the same position as it had entered. 



204 



PHYSIOLOQ ) OF LABOR. 



After the Leading pole begins to pass the Lower end of the symphysis 
[ts forward rotation is favored by the fact that this direction is that of 
least resistance. 

Fro. 182 




Beginning distention of pelvic floor. (Farabeuf and Varnier.) 
Fig. 183. 




Beginning extension of head. (Farabeuf and Varnier.) 

Extension. By the time the occiput is about to emerge under the pubic 
arch the sinciput rests firmly upon the coccyx and lower portion of the 
sacrum. The biparietal diameter lies in the grasp of the ischial tuber- 
osities and the vertex distends the pelvic floor. Fig. 182. The long 
diameter of the head lies nearly in line with the sacro-pubic diameter of 
the pelvis. 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 205 



As the head is driven down the distention of the pelvic floor is 

increased. The floor grows progressively thinner as it stretches under 

the pressure of the advancing head, and becomes more and more 

elongated antero-posteriorly till at the moment of expulsion the length 

of the sacral segment, from coccyx to the posterior edge of the vulva, 

is 6 inches. 

Fig. 184. 




Maximum distention of pelvic floor. Equator of head about to pass. (Farabeuf and Varnier.) 

Fig. 185. 




Occiput rides up in front of symphysis. Pelvic floor retracts. (Farabeuf and Varnier.) 

As the occiput escapes under the arch of the pubes it rides up in front 
of the symphysis till the nucha rests against the subpubic ligament. 
Pivoting upon this the head is expelled by a movement of extension, the 
vertex, the forehead, and the face successively sweeping over the free 
edge of the sacral segment of the pelvic floor. Figs. 183, 184, and 185. 



206 



PHYSIOLOGY OF LABOR. 



Throughout its descent the head advances with the pains and recedes 
in the intervals. In normal conditions this alternate advance and 
recession continues during expulsion till the head is well in the grasp 
of the Volvo-vaginal ring. From this time no recession takes place 
between the pain-. 

Restitution. The rotation of the head in course of its transit through 
the pelvis develops a certain degree of torsion of the neck. As the head 
18 expelled the neck untwists. The head, therefore, immediately it is 
horn, assumes a position corresponding to that in which it had entered 
the pelvis. This movement is termed restitution. It is of interest for 
the reason that it indicates the primary position of the head. Fig. 186. 

Fig. 186. 




Fcetal bead after restitution. Shows also caput succedaneum. (Ribemont-Dessaignes and Lepage.) 

External Rotation. The shoulders descend in the oblique diameter of 
the pelvis opposite that in which the head came down. They rotate, 
therefore, in a direction opposite that which the head had pursued. 
Rotation of the head is accordingly continued during the expulsion of 
the shoulders and in the same direction as that which obtained in the 
movement of restitution. This supplementary rotation is termed ex- 
ternal rotation. 

Delivery of the Trunk. The shoulders engage in the oblique diameter 
of the pelvis opposite that in which the head entered. They rotate less 
perfectly than the head. The anterior shoulder is arrested behind the 
symphysis and the posterior shoulder rides over the pelvic floor and, as 
a rule, first appears at the vulva. After expulsion of the posterior, the 
anterior shoulder is disengaged and escapes. The breech undergoes only 
partial rotation. As the trunk is expelled it is followed by a gush of 
bloody water. 

Clinical Phenomena of the Second Stage. 

If the patient is very much fatigued from a long first stage she may 
sleep between the pains. These brief periods of rest help to renew her 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 207 

strength and add to the efficiency of the pains. The parturient is much 
more likely to sleep if chloral has been administered in the first stage. 

The pains are more severe during the stage of expulsion, but the 
patient realizes with a sense of satisfaction that the head advances with 
the pains, and the hope of speedy relief fortifies her endurance. 

When the occiput has reached the pelvic floor, the cavity of the pelvis 
is completely filled and the pressure of the head gives rise to marked 
rectal tenesmus. The sphincter ani becomes relaxed and one or more 
fecal evacuations usually take place as the head passes over the floor of 
the pelvis. The contractions of the abdominal muscles toward the close 
of the expulsive stage are reflex and wholly involuntary. As the head 
distends the vulvar ring the pains become so intense as sometimes to 
result in transient delirium. 

A brief pause ensues on birth of the head. After a moment or two 
of rest, contractions recur and the shoulders pass ; then the body, fol- 
lowed by a gush of bloody amniotic fluid, is expelled. 

The second stage is now ended, and a period of a few moments follows 
before the pains are again renewed to expel the afterbirth. 

Moulding of the Head. Even in typical normal labors, the head under- 
goes more or less alteration in shape as it is driven into the pelvic brim. 
This is an important fact in the mechanism of labor, since it conduces 
in marked degree to the adaptation of head to pelvis. 

Under the influence of the pelvic pressure forces the diameters in the 
grasp of the resisting girdle are all reduced, this reduction being compen- 
sated by elongation of the cephalic mass in the direction of the birth-canal. 
The engaging diameters are thus diminished to the average extent of 
6 mm., \ inch. The degree of moulding will obviously depend on the 
relative size of head and pelvis and the plasticity of the cranial vault. 
The plasticity varies with the extent of ossification, which is not abso- 
lutely constant at the same stage of development. 

Moulding is an essential element in the mechanism of the expulsive 
stage of labor not only by reason of adaptation of head to pelvis, but 
also because elongation of the head favors normal rotation by increasing 
the dip of the leading pole. 

Caput Succedaneum. The caput succedaneum is an oedematous swell- 
ing which is developed on the presenting part in course of the birth. It 
is formed after rupture of the membranes. During a uterine contraction 
all parts of the fcetal mass are under pressure except that which offers 
to the examining finger within the girdle of resistance. The vessels of 
the presenting part become engorged during the pains and a serous 
exudate takes place into the cellular tissues of that portion of the foetal 
surface. See Fig. 186. 

The size of the caput succedaneum will obviously vary with the 
degree of force which produces it. It is large, therefore, in prolonged 
and difficult labors. Its size affords a valuable sign in the vaginal 
examination of the degree of obstruction which the foetus encounters in 
its passage through the pelvis. 

The location of the caput succedaneum is of interest in the examina- 
tion of the head after delivery as indicating the positiou in which the 
head had descended. In anterior positions it is situated at the posterior, 
and in posterior positions on the anterior aspect of the summit of the 



208 PHYSIOLOGY OF LABOR. 

head. En left positions it occurs to the right, and in right positions to 
the left of the median line. A righl occipito-poeterior locution of the 
caput, therefore, indicates a left occipito-anterior position of the head, 

and so on. 

It should be remembered that the situation of the tumor may be 
modified when the head has been subjected to long-continued pressure 

in the lower portion of the birth-canal after partial rotation had taken 

place. 

The caput, like moulding, by adding to the elongation of the leading 

pole of the head, promotes rotation. In labor- in which the head 
furnishes the dilating wedge it adds to the efficiency of the dilator by 
increasing the acuteness of the wedge. 

A similar swelling develops on the presenting part in other than 
cephalic presentations. To this it is customary to apply the same term 
on whatever part of the foetal surface it occurs. The tumor usually 
disappears within twenty-four hours after birth. 

The Mechanism of Placental Expulsion. 

After expulsion of the child the uterus grows smaller by retraction 
and closes about the placenta. When active contractions are again 
resumed the placenta is gradually detached. As the seat of placental 
attachment shrinks during a uterine contraction, the placenta not being 
sufficiently retractile to accommodate itself fully to the diminished area 
of the placental site, it is partially torn from the uterine wall with each 
pain. Rarely it may happen that the placenta is wholly separated by 
the first strong contraction. The placenta will then probably be forced 
out folded on itself from side to side, presenting by its edge. 

If the placenta is not wholly detached at the first expulsive efforts, a 
different mechanism may obtain. Detachment sometimes takes place 
first over the central portion of the placental seat. Then, as the uterus 
relaxes, a retro-placental blood clot is formed. With each succeeding con- 
traction the area of detachment is increased and the clot grows accord- 
ingly. The liberated portion of the placenta is thus thrust downward 
toward the cervical opening and the afterbirth is expelled flatwise by its 
amniotic surface. 

When it is extruded, with its edge presenting, the grasp of the uterus 
acts directly upon the placenta. When it is dissected off by the blood 
clot its expulsion is partly due to the extruding force propagated through 
the retro-placental blood clot during the uterine contractions. Figs. 
187 and 188. 

The membranes are last to be detached. In either method of expul- 
sion the placenta is thrust downward through the rent in the membranes 
and the latter are peeled off by traction of the placenta. 

It is obvious that the passage of the placenta with its long diameter 
corresponding to the long diameter of the uterus is most favorable to 
easy expulsion. 

Persistent adhesion of the membranes may prevent the placenta from 
being delivered with its long diameter in conformity with the long 
diameter of the uterus. Pulling on the cord, by pulling down the 
central portion of the placenta, may act with like effect. 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 209 

Fig. 187. Fig. 168. 





Showing the two methods of placental expulsion. (Schroeder. 



The Clinical Phenomena of the Third Stage. 

At a variable length of time after the child has been delivered the 
uterus again commences to contract, the placenta is gradually forced 
into the vagina, and, when the muscular tonicity of the pelvic floor has 
not been too much impaired, may be expelled from the vulvar orifice. 
The membranes are dragged after it, sometimes promptly, sometimes 
peeling slowly from their uterine attachment. 

The expulsion of the placenta is accompanied with a greater or less 
amount of clotted and of liquid blood. The total quantity of blood 
lost during the third stage, together with that expelled at the birth of 
the child, should not, in strictly normal conditions, exceed a pint. 

After-pains. After the expulsion of the placenta there is a pause of 
variable length in the uterine contractions. The contractions of this 
period are termed after-pains. They are not usually painful in primi- 
parae. In multipara? they are frequently violent enough to cause con- 
siderable distress. Severe after-pains are due, as a rule, to the retention 
of blood-clots in the uterus. This occurs more frequently in women 
who have borne children, owing to the greater relaxation of the multi- 
parous uterus. In the presence of clots the uterine contractions become 
more powerful in the effort to expel them. 

Retraction of the Uterus. Normally the after-pains serve a useful 
purpose. They bring about retraction, by which the active contractile 
portion of the uterus becomes shorter and thicker. The vessels, which 

14 



210 PHYSIOLOGY OF LABOR. 

are intimately interwoven with the muscular bundles, are thus securely 
ligated. 
The peritoneal covering of the uterus accommodates itself to the 

diminished volume of the organ by reason of its elasticity. The uterine 

peritoneum presents no loose folds, as a rule, even after complete re- 
traction. 

Situation of the Uterus. On examination over the abdomen at the 

close of labor, the fundus is felt about half-way from pubes to umbilicus; 

normally it becomes as hard as a billiard ball during after-pains, relax- 
ing only partially in the intervals. 

Lower Uterine Segment. The lower uterine segment and the cervix 
remain passive for several hours after labor. The cervix presents a 
soft and almost >hapeless mass scarcely distinguishable by the touch 
from the loose vaginal folds. Within a few hours the tonicity of its 
muscular structures begins to be re-established and the cervix to resume 
its usual shape. 



CHAPTEE IX. 

THE MANAGEMENT OF NORMAL LABOR. 

PREPARATORY TREATMENT. 

No more important duties devolve upon the obstetrician than those per- 
taining to the observation and care of his patient in preparation for labor. 
Until recent years this part of his responsibility was too often overlooked. 
Happily, to-day the necessity for prophylaxis against the possible ills and 
accidents of childbed is generally recognized. The enforcement of hygi- 
enic rules, the regulation of the health and habits of the patient during 
pregnancy, is vital to the successful conduct of the obstetric case. Even 
minor departures from the normal course of gestation should receive 
the attention of the physician and, as far as possible, be corrected. Es- 
pecially ought he to inform himself in advance of the relative size of 
head and pelvis, of the presentation and position of the child, and, if 
possible, of all the facts of the individual case which may bear upon the 
issue of the labor. 

Urinary Examinations. The excretory activity of the kidneys should 
be watched from the first. In the last two months of gestation system- 
atic examinations of the urine should be made weekly. The physician 
should not trust to a mere test for albumin. Albuminuria is not neces- 
sarily attended with marked toxaemia, nor is grave toxaemia in pregnant 
women always associated with albuminuria. Most essential are sys- 
tematic quantitative determinations of the urinary solids. Especially 
significant is the daily excretion of urea. Though this particular solid 
is not a prominent factor in the toxaemia of pregnancy, the quantity of 
urea affords a fairly reliable index of the eliminative activity of the 
kidneys. It must not be forgotten, however, that the amount of urea 
and of the total urinary solids must vary with the character and quantity 
of food ingested and from other causes. The general condition of the 
patient should be taken into account as well as the urinary findings. 

Tests for Albumin. For clinical use a good test for albumin is Esbach ? s. 
The reagent consists of picric acid, 10 grammes; citric acid, 20 grammes; 
water, 1000 grammes. The urine is mixed in a test-tube with an equal 
volume of the test solution. Heat and nitric acid, nitric acid cold by 
the contact method, or Tanret's test, with suitable precautions, are con- 
venient and reliable tests for albumin. 

Urinary Solids. One of the ready methods of computing the daily 
quantity of urinary solids is that of Haines, which is as follows: Multi- 
ply the last two figures in the number representing the specific gravity 
by the number of ounces of urine voided in twenty-four hours, and the 
resulting product by l T l 7 . This gives approximately the number of 
grains of solid matter in the given volume of urine. The average 
amount of solids in health, it will be remembered, is 1000 grains. 

Urea. For the estimation of urea the following method from Bart- 

(211) 



212 PHYSIOLOGY OF LABOR. 

ley's ( '"A* misfri/ is recommended: "A graduated tube (Fig. 189) is filled 
to the fifth division with a 20 per cent, aqueous solution of potassic 

bromide. Chlorinated soda solution (Squibb) 18 then added to the 
fifteenth or twentieth division. Pure water to the depth of one inch is 
now floated upon the contents of the tube. [tie ni<»t easilv deposited 
there with the aid of a pipette. (Fig. 190.) One C.C. of urine is then 
floated upon the water, taking care that the Liquids do not mix. The 
open end of the tube is now quickly closed securely 
fig. 189. fig. i9o. by pressing the thumb firmly upon it. The con- 
tents are mixed by gently shaking. When the 
effervescence has ceased, the reading is taken at the 
top of the liquid column, while the tube is held 
inverted. The end of the tube, still closed bv the 
thumb, is now submerged in a large jar of water. 
The thumb is then removed, and the tube raised 
or lowered, till the surface of the liquid in the 
u tube is at the same level with that in the jar, and 

i6 the reading is again taken. The difference be- 

i8 tween the two readings indicates the number of 

grains of urea in a fluidounce of the urine. This 
number multiplied by the number of fluidounces 
of urine voided in twenty-four hours gives in 
grains the total quantity of urea excreted during 
the day. The average daily amount is about 500 
grains, but is liable to considerable variation 
within normal limits. The subject will be treated 
more fully under eclampsia. 

The Nipples. Inquiry should be made with refer- 
ence to the condition of the nipples. If they are 
small, depressed, or misshapen the patient should 
Graduated tube. Pipette. be directed to draw them out daily with the thumb 
and fingers. The manipulation not only helps to 
develop the nipples, but it renders them less liable to injury by the 
child's mouth in nursing. 

Inversion and other deformities of the nipples are often the result of 
pressure from tight clothing; for this the remedy is obvious. 

The sebaceous secretion which accumulates upon the nipples affords a 
nidus for the growth of micro-organisms, and uncleanliness is doubtless 
a prominent factor in infection of the nipples and resulting mastitis 
during lactation. Special attention should be paid to the cleanliness of 
these parts during the later months of pregnancy. A borax solution, one 
tablespoonful to the pint of water, is a good detergent. Bathing with 
this once daily is useful as a prophylactic against the occurrence of sore 
nipples during the nursing period. 



ANTEPARTUM EXAMINATION. 

The obstetrician should inform himself before labor of the presentation 
and position of the child, the relative size of head and pelvis, and, as far 
as possible, of all the obstetric facts which may bear upon the result of 



THE MANAGEMENT OF NORMAL LABOR. 213 

the labor. This is usually done at about the end of the eighth month. 
The antepartum examination is conducted according to the following 
scheme : 

A. Abdominal Examination. 

Diagnosis of Presentation and Position of Fcetus. 

Preparation. The patient lies in the horizontal position on a hard bed or 
table, the examiner standing or sitting at either side. The bladder and 
the rectum must be empty. The abdomen may be wholly exposed or be 
covered with a thin sheet. If the sheet is used the examination is con- 
ducted through it or with the hands on the abdomen beneath it. The 
examiner first bathes his hands in warm water. This renders the tactile 
sense more acute and tends to prevent reflex contractions of the abdom- 
inal and uterine muscles which would be excited by contact of cold 
hands. 

Location of Child's Back and the Small Parts. Three methods are avail- 
able. One or all may be employed. 

1. The child's back and the limbs or small parts can usually be made 
out by palpating systematically the entire surface of the abdominal tumor. 
Only the volar surfaces of the finger-tips are applied, and the touch 
should be light. The tactile sense is keenest with but moderate pressure. 
Deeper pressure is only occasionally necessary to make out the degree 
of resistance, the hardness, and the mobility of the foetal parts beneath 
the fingers. 

The small parts are felt as small nodules, knees, ankles, elbows, etc., 
which glide about freely under the touch. They are identified by cir- 
cling motions of the fingers with moderate pressure. Sometimes a foetal 
extremity can be mapped out through the greater part of its length. 

2. The foetal dorsum is more readily palpated if the trunk is steadied 
by pressure in line with the long axis of the foetus, the hand being held 
over the upper foetal pole. This increases the convexity of the dorsal 
plane and brings it nearer to the examining hand. 

3. Applying one hand flat on the middle section of the abdomen, mod- 
erately deep pressure displaces the foetus to the side toward which its 
back lies and the liquor amnii to the opposite side. Still maintaining the 
pressure, the hard body of the foetus may be felt on one side of the abdo- 
men and only fluid on the other side. (Fig. 191.) 

By these simple manipulations it is usually possible to determine at 
once whether the child's back lies to the right or the left of the mother. 

To learn whether the back of the child is turned toward the back or 
front of the mother it will be necessary to distinguish the dorsal from 
the lateral plane of the foetus. The back offers a broad resisting surface< 
which is somewhat convex from end to end, and which runs off smoothly; 
upon the head. The lateral plane of the foetus is narrower; it is notj 
convex from end to end, and a sulcus is felt between it and the head. j 

Except in twins, where legs and arms can usually be felt in various 
directions, finding the small parts in one section of the abdomen confirms 
the location of the dorsum in the opposite region. Small parts to the 
right indicate a left, small parts to the left indicate a right position of 
the foetus. Small parts few and hard to find suggest an anterior position 



214 PHYSIOLOGY OF LABOR. 

of the child; small parts numerous and found near the middle section of 
the abdomen usually point to a dorso-posterior position of the foetus. 
If small parte oan be felt beyond either end of the foetal ellipsoid, that 
end Is pretty Burely the breech. 




Displacing foetus to one side of abdomen for locating dorsal plane. 

The examination, thus far, as a rule, presents little difficulty. When 
the abdominal wall is over-fat or rigid, the uterus contracted, or tense 
from distention, as in hydramnios and certain other conditions, the foetal 
parts are often more or less obscured. 

Palpation of the Lower Foetal Pole. The hands are placed over the 
lateral aspects of the lower abdomen with their palmar surfaces nearly 
facing each other, the finger-tips toward the mother's feet. The ends of 
the fingers should rest at first a little above Poupart's ligament. The 
hands are pressed downward toward the excavation, and backward 
toward the mother's back, till the lower foetal pole is caught between 
them. (Fig. 192.) If not readily found the object may sometimes be 
gained by moving the hands sharply from side to side, as if to toss the 
foetal pole from one hand to the other, the hands meantime being brought 
nearer and nearer together. 

The first object now is to find whether the foetal pole under examina- 
tion is the head or the breech. The two poles are distinguished by the 
following characteristics: The head is hard and globular, and it presents 



THE MANAGEMENT OF NORMAL LABOR. 



215 



a sulcus laterally between itself and the trunk. Again, the head is the 
only foetal part that sinks into the pelvic excavation before labor. In 
primigravidse, as a rule, the head when it presents is found in the lesser 
pelvis during the last one or two months of pregnancy; in multigravidse, 
owing to greater laxity of the abdominal walls, it lies above it till the 
period of lightening, and in two-thirds of the cases till labor begins. 
When, therefore, the presenting pole of the foetus is found in the excava- 
tion before labor, that pole is the head. The breech is alone smaller, 
with the extremities larger, than the head. It lacks the hardness and the 
globular shape of the head; it presents no sulcus, and in all cases it lies 
above the excavation till labor is established. 



Fig. 192. 




Palpation of lower foetal pole. 

The presence of the lower foetal pole in one iliac fossa means a trans- 
verse presentation. 

Palpation of the Upper Foetal Pole. The hands are placed on the abdo- 
men over the upper portion of the uterus with the finger-tips toward the 
mother's head, the volar surfaces of the hands nearly facing each other. 
(Fig. 193.) The upper foetal pole is now palpated for the distinguishing 
marks of the head or the breech. The poles are distinguished by the 
characters already given and by the fact that the head when in the upper 
uterine segment is susceptible of ballottemept. The head can be tossed 
from side to side between the hands, or be made to bob under the fingers 



216 



I'llYSIOLOQY OF LABOR. 



by light intermittent thrusts through the abdominal wall with one 
hand. 

The brooch lacks the flexible attachment to the trunk which marks the 

head, and it bafl little mobility not only because of this, hut also hv 
reason <>f the greater hulk of the component elements of the pelvic end 
of the foetal ovoid. 

Fig. 198. 




Palpation of upper foetal pole. 

Location of the Anterior Shoulder. The hands are held firmly upon the 
abdomen over the sides of the foetal head and without relaxing the press- 
ure moved toward the trunk. The first obstacle encountered is the 
anterior shoulder. It is more surely identified by palpating it with one 
hand while the other steadies the foetus by downward pressure upon 
the breech in the direction of the foetal axis. (Fig. 194.) It presents 
a small rounded prominence immovably attached to the trunk. Some- 
times its anatomical elements can be traced. 

Finding the anterior shoulder on the left of the median line of the 
abdomen in vertex presentation indicates a left, on the right a right posi- 
tion of the foetus. Anterior shoulder within one or two inches of the 
median line indicates an anterior, several inches from the median line a 
posterior foetal position. 

Location of the Cephalic Prominence. When the head lies in the exca- 
vation in vertex presentation the occipital pole, owing to head flexion, 
sinks more deeply in the cavity than the sinciput. The latter lies at or 
just above the brim; therefore, the greatest cephalic prominence at the 



THE MANAGEMENT OF NORMAL LABOR. 



217 



brim corresponds to the sinciput. It is located by laying the hand 
across the lower abdomen just above the symphysis and grasping the 
head (Figs. 195 and 196). The situation of the greater prominence 
may also be made out by palpation with both hands, as shown in Fig. 
197. The hand on the side on which the occiput lies sinks more deeply 
into the excavation than the other. The prominence of the sinciput is 
naturally most marked in occipito-posterior positions. 



Fig. 194. 




Locating anterior shoulder. 



Location of the Foetal Heart. Auscultation may be practised with or 
without the stethoscope. The room must be still. For immediate aus- 
cultation, without the stethoscope, the abdomen is covered with a thin sheet 
or towel. Since a continuous solid medium helps conduction, the abdom- 
inal wall should be pressed firmly against the uterus. Downward press- 
ure of the breech in the direction of the long axis of the foetus facilitates 
the examination by thrusting the dorsum forward. The focus of auscul- 
tation, the point at which the heart-tones can be heard loudest, as a rule, 
nearly overlies the lower angle of the left foetal scapula. 

Foetal heart on the left of the median line indicates a left, on the 
right, a right position of the foetus. Foetal heart near the median line 
points to an anterior, far away from it, to a posterior foetal position. 



218 



PHYSIOLOGY OF LABOR. 



When the foetal heart is above the umbilicus the presentation la generally 

8 breech, when below it, a vertex presentation. The location of the 



Fig. 195. 







Locating cephalic prominence by grasping foetal head with hand held across 
the suprapubic region. 

Fig. 196. 




Diagram showing relation of hand to fcetal head in manipulation for locating 
cephalic prominence. 



THE MANAGEMENT OF NORMAL LABOR. 



219 



heart-tones, however, cannot be wholly relied on for the diagnosis of 
presentation. The heart lies nearly midway between the two extremities 
of the foetal ellipsoid. Its height in the abdomen is, therefore, not mate- 
rially affected by the presentation in multigravidse in whom neither foetal 
pole sinks into the excavation before labor. In primi gravida?, in whom 
the foetus rests lower in vertex than in breech presentation, the location 
of the foetal heart is of some value for the diagnosis of presentation. 



Fig. 197. 




Diagram showing method of locating cephalic prominence by palpation with 
both hands. 



Sometimes it happens that the focus of auscultation does not immedi- 
ately overlie the heart. It may be found at some remote point in con- 
sequence of firmer contact of the foetus with the uterine wall at that 
point. For a like reason a second focus may in rare instances be found. 

In dorso-posterior positions, in hydramnios and in certain other con- 
ditions, the heart-sounds are not always audible. 

Conclusions. A complete abdominal examination usually affords more 
reliable data for determining the foetal presentation and position than 
does the internal examination. With rare exceptions a definite and posi- 
tive diagnosis is easily reached. The examiner should accustom him- 
self to reserve his decision till the facts are all in hand, basing his 
conclusion upon the sum total of the findings. 

Abnormal Conditions. 

In course of the abdominal examination pathological conditions of 
maternal or foetal origin that may complicate the labor are to be looked 
for. Morbid growths in the abdomen or pelvis may be detected by 
palpation. The presence of hydramnios or of pendulous abdomen are 
noted. Excessive size and persistent tension of the uterine tumor should 
suggest twins. A definite diagnosis is usually possible. Hydrocephalus 



220 PHYSIOLOGY OF LABOR. 

OUght to be recognized by palpation. It is more surely made out by 
measurements taken through the abdominal wall with calipers. 

The location of the placenta when implanted anteriorly can sometimes he 

determined in the external examination. The convex margin can occasion- 
ally be felt as a resisting ringj within the placental area the foetal parts are 

obscure to the touch, while elsewhere they are easily detected. Thus the 

diagnosis of placenta previa is sometimes possible by external palpation. 

External Pelvimetry. 

In connection with the abdominal examination external measurements 
of the pelvis are to be taken, except in cases in which there is ample 
assurance from the character of previous labors that the pelvis is normal. 
Extreme contraction or marked asymmetry is readily recognized by 
palpation. Slight deformities are detected only by systematic measure- 
ment. For this purpose a suitable pelvimeter will be required. (Fig. 
198.) Most essential are the antero-posterior diameter of the pelvis or 

Fig. 198. 




Collyer's pelvimeter 



the external conjugate, the interspinal, the intercristal, and the external 
oblique diameters. Of these the diameter of greatest practical value is 
the external conjugate. 

The external conjugate is measured from the fossa just below the spine 
of the last lumbar vertebra to a point on the pubic surface just below 
the top of the symphysis. (Fig. 199.) To locate the last lumbar spine 
draw an imaginary line between the dimples corresponding to the pos- 
terior superior iliac spines. The second vertebral spine above this line is 
the last lumbar. The external conjugate diameter, or, as it is sometimes 
called, the diameter of Baudelocque, is nearly parallel with the plane of 
the brim and with the internal conjugate. 



THE MANAGEMENT OF NORMAL LABOR. 



221 



The method of measuring the intercristal diameter (Fig. 200) and the 
interspinal diameter is obvious. 

The external measurements are fairly reliable as evidence of the shape 
and capacity of the pelvis internally. When all are small the pelvis is 
generally contracted. If the interspinal is equal to or greater than the 
intercristal diameter the pelvis is flattened. Inequality in the external 
oblique diameters is evidence of asymmetry. 



Fig. 199. 




Measuring the external conjugate. The dimples corresponding to the posterior 
superior spines of the ilium are shown in the figure. 

To find the true conjugate from the diameter of Baudelocque, from 7 
to 12.5 cm., 2f to 5 inches, must be deducted from the latter, according 
to the estimated thickness of the bones and the soft parts, the inclina- 
tion of the symphysis, and the height of the sacral promontory. 

Fig. 200. 




Measuring the intercristal diameter. 



Since it is impossible to know the exact allowance to be made in a 
given case, the external conjugate cannot be wholly relied on for detect- 
ing pelvic contraction. Yet it may safely be assumed that the pelvis is 






222 PHYSIOLOQ Y OF LABOR. 

flattened when the diameter of Baudelocque falls below 16.5 cm., 6) 
inches, or that it is ample when the external conjugate exceeds 21 cm., 
%\ inches. As a general rule, contraction should be Buspected when the 
externa] conjugate is Less than Ls cm., 7 inches; the true conjugate is 
probably, though by no means surely, ample when the external conjugate 

is above 18 Cm. 

B. Vaginal Examination. 

An internal exploration is advisable in all cases as a part of the pre- 
liminary examination; in women pregnant for the first time and in otters 
whose obstetric history leads to suspicion of pelvic deformity, it is im- 
perative. The objects are to learn the condition of the soft parts — vulva, 
vagina, cervix, especially in multigravidee — to confirm the diagnosis of 
presentation, to detect a possible vicious insertion of the placenta, and to 
determine the capacity of the bony pelvis. 

Antiseptic Preparation. The external genitals of the patient and the 
hands of the examiner should be prepared with the same care as for 
internal examinations during labor. For the technique of disinfection 
the reader is referred to page 228. 

Examination of the Soft Parts. In multigravidse the vulva, the vagina, 
and the cervix are first examined for injuries resulting from previous 
deliveries. In all cases it should be noted whether pathological growths 
or congenital defects of the soft parts, which may complicate the labor, are 
present. A cephalic presentation, as a rule, can readily be made out by 
the touch through the uterine walls. A low implantation of the placenta 
in advance of the head should be readily detected. 

Internal Pelvimetry. Most important is the examination of the bony 
pelvis. This should include the pelvic inclination, the configuration of 
the pelvis, the depth and inclination of the symphysis pubis, the shape 
of the sacrum, the height of the promontory, and the relative size of 
the head and pelvis. The pelvic diameters, especially at the inlet and 
the outlet, should be definitely determined. 

For internal pelvimetry the hand, as a rule, is the best instrument. 
The shape of the sacrum and the general capacity of the pelvis can be 
approximately estimated by palpation. 

The Pubococcygeal Diameter is measured by placing the end of 
the second finger against the tip of the coccyx and bringing the radial 
edge of the outstretched hand in contact with the subpubic ligament. 
The point at which the latter rests against the hand is then marked by 
a finger of the other hand. On withdrawing the hand the distance be- 
tween the two points of contact is measured with tape or calipers. 

The Sacropubic Diameter is measured in like manner. 

The Transverse Diameter at the outlet is best measured externally. 
With the patient in the lithotomy position the examiner places the 
thumbs upon the skin over the ischial tuberosities. The palmar surfaces 
of the thumbs are pressed firmly against the inner aspects of the tuber- 
osities at the level of a line running through the anterior margin of the 
anus. The distance between the two points of contact is then measured 
by an assistant. Under an anaesthetic during labor this diameter may 
be estimated also by introducing the extended hand partly within the 



THE MANAGEMENT OF NORMAL LABOR. 



223 



vaginal orifice between the tuberosities, and comparing the bisischial 
space with the width of the hand near the finger-tips. 

The Diagonal Conjugate is measured as follows: With the patient 
in the lithotomy position two fingers of one hand are passed into the 
vagina. If the head is found resting deeply in the lesser pelvis in the 
ninth month of pregnancy the relative capacity of the brim is assured 
and the measurement is unnecessary. Should only the occipital pole 
have sunk into the excavation it is to be pushed up. The finger-tips are 
carried up and down over the region of the sacral promontory till the 
most prominent point is found. Against this the ulnar margin of the 
second finger-tip is held firmly. The radial edge of the hand is then 
raised till it rests against the subpubic ligament. The latter point of 
contact is marked by a finger-nail of the other hand. (Fig. 201.) On 

Fig. 201. 




Manual method of measuring the diagonal conjugate. 

withdrawing the hand the distance between the two points of contact 
is measured as in the case of the pubo-coccygeal diameter. 

The Tetje Conjugate is computed from the diagonal, since the former 
cannot be measured directly. The diagonal conjugate corresponds nearly 
to the hypothenuse of a triangle of which the base is the true conjugate. 
Generally the latter is obtained by subtracting from a half to three- 
fourths inch from the diagonal conjugate. The amount to be deducted, 
however, will vary with the depth and the thickness of the symphysis 
pubis, with its inclination, and with the height of the sacral promontory. 

As these elements in the question are variable and their value in the 
individual case cannot be determined with accuracy, the estimation of the 
true conjugate by the foregoing plan is only approximate. A. possible 
error of at least a quarter of an inch must be assumed in all cases; 
frequently it is greater. 

For more exact determination of the true conjugate Hirst, with an 
instrument of his own device, measures the distance from the promon- 
tory to the anterior aspect of the symphysis two-fifths inch below its 
upper margin. The thickness of the pubic joint is then measured, with 



224 



PUYSIOLOCY OF LABOR. 



the same instrument, and the difference between the two measures gives 
the precise value of the true conjugate. 




V^ $? <i .T \*>A PvHtt S^O . 

Hirst's pelvimeter adjusted for measuring from promontory to front of symphysis. 

Fig. 203. 




&.-utVMvnua«.co. 
Pelvimeter adjusted for measuring thickness of symphysis. 



CASE RECORDS. 

The habit of keeping systematic records conduces to thoroughness in 
the management of cases. It would be well if physicians in private 
practice, as in hospital work, made use of blanks for obstetric histories. 

The following is a simple form for obstetric records which may be 
modified to suit the requirements of individual practitioners: 



Case of 



Obstetric Recoed. 

Application No. 
Date of application 189 



Residence 

para 
Miscarriages 
Last menses, date 
Quickening, date 



General health 

Heart 

Lungs 



HISTORY. 

Nationality 
Character of previous labors 

duration 



Married Single Widow 
Puerperiums 



quantity 



ANTE-PARTUM EXAMINATION. 

Date 



Urine - 



f Reaction 

j Specific gravity 

I Albumin 

Sugar 

Casts 

Amount 

Total solids 

Urea 



Breasts 



f Size 
j Veins 
-{ Areolae 
| Nipples 
I Papilla? 



189 



THE MANAGEMENT OF NORMAL LABOR. 



225 



Dorsum of foetus, to mother's front 
Foetal head, where found 

Anterior shoulder, where found 



ABDOMINAL EXAMINATION, 
left 



back, right 
size 



Foetal movements 

f Rate 
Rhythm 
Force 
Location 



Foetal heart \ 

I 



Height of fundus above symphysis 

Liquor amnii, scanty normal excessive 

Foetus, one two Length of foetal ovoid 

External conjugate Interspinal diameter Intercristal diameter 

Location of placenta Complicating tumors 

VAGINAL, EXAMINATION. 

Condition of vulva, old injuries oedema rigidity 

f Mucous membrane, healthy or not j o- ^ 1 10n 

j Softening 
[ Old injuries 
Diagonal conjugate True conjugate Other diameters 



Obi 



ques 



Vagina \ Secretion, healthy or not 
[ Other abnormalities 



Dilatation Stage. Pains began 
General condition of patient 



LABOR. 




Date 




frequencv 


character 


Temperature 


Pulse 



Bladder, full or empty 
Presentation 



Foetal heart 



Rectum, full or empty 
Position 
Rate 
Rhythm 
Force 
Location 
Number of vaginal examinations 
Complications and medication 

Expulsion Stage. Pulse 
f Rate 

F««.l heart \ *^» 

{_ Location 
Membranes ruptured, when 
Perineal stage, duration 
Number of vaginal examinations 
Complications, medication, operations 



189 



Membranes ruptured or not 
Posture 



Temperature 



Duration 
Character of pains 



Vaginal secretion, free or scanty 

how 
management 



Duration 



Placental Stage. 






Placenta, delivered at 


method 




size shape 


seat 


anomalies 


Membranes, complete or not 


how removed 




Umbilical cord, insertion 


length 


anomalies 


Uterus, degrees of retraction 


height of fundus 


shape 


Injuries 


* Medication 




General condition of patient 


Pulse 


Temperature 



Child, male female, alive dead, length 



weight 



on 



OF 



Head •[ Diameters 

\ Circumferences \ 
Inj uries 

Congenital anomalies 
Temperature in rectum shortly after birth 



SOB 



BIP 



BIT 



Rectum and urethra, pervious or not 



15 



226 



PHYSIOLOGY OF LABOR. 



SUBSEQUENT HISTORY. 



TEMPERATURE AND PULSE 



Day 
Dato 
Temp. 

m 

105 

104 

103 

102 

101 

100 

99 

98 

Pulse 

180 

170 

160 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 



1 


8 


3 


i 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































MOTHER. 



Diet 
Bowels 

Uterus 
Treatment 



Breasts 

Bladder 

Lochia 



CHILD. 

General condition Temperature 

Eyes 

r Mouth 
Digestive organs -j Stomach 

( Bowels 
Bladder Umbilical wound 

Weekly gain in weight 



CONDITION ON DISMISSAL. 



General condition of mother 

Uterus, size 

Cervix, size shape 

Vulva and vagina, injuries 

Child 



position 



position 



Date 

shape 

injuries 



1S9 



THE MANAGEMENT OF NORMAL LABOR. 227 

Obstetric Armamentarium. Such instruments and drugs as are likely 
to be needed in the conduct of ordinary labor and in the more important 
emergencies of the lying-in room should be carried in the obstetric bag. 
The usual outfit comprises : a pelvimeter, an obstetric forceps, a hypo- 
dermic syringe, a gravity or a Davidson syringe, a glass douche tube, a 
soft rubber catheter, a soft-rubber tube with bulb attached for clearing the 
child's pharynx in case of partial asphyxia, a Sims speculum, a double 
tenaculum, a straight uterine dressing forceps, a curette about 14 inches 
in length, needle forceps, needles moderately curved and of assorted sizes 
from 4 to 7 cm., or 1J to 2 J inches, in length for suturing lacerations; 
scissors, aseptic sutures of catgut and of silk and of silkworm-gut in 
hermetically sealed bottles or glass tubes, a straight blunt-pointed bis- 
toury for episiotomy, two hand-brushes, a set of dilating water-bags, 
and a sealed package of 2 per cent, iodoform gauze, enough to fill the 
post-partum uterus. 

The drugs most frequently needed are: chloroform, ether, ergot, digi- 
talis, veratrum viride, trinitrin, morphine, chloral, and mercuric chlo- 
ride or iodide. All except the anaesthetics may be had in tablet form. 

A useful apparatus in forceps delivery in the absence of competent 
assistance is Buckmaster's sling for holding the thighs flexed on the 
abdomen. It is about five inches wide and two yards long, and is made 
of ticking. At one end is a loop, which is slipped over* one knee. The 
band is carried over one shoulder, across the back, under the other 
shoulder, and fastened about the other knee. If made of thin material 
it occupies but little room in the obstetric bag. 

Obstetric Antisepsis. 

To an obstetrician, Ignatius P. Semmelweis, belongs the credit of first 
putting into practice the principles of the present antiseptic system. In 
1847, while an assistant in the Lying-in Department of the Vienna Gen- 
eral Hospital, he was deeply impressed by the high mortality that pre- 
vailed in the service. This mortality he soou found was greatest in the 
students' clinic. Nearly 10 per cent, of the women delivered in that 
branch of the service died. The students were engaged in the work of 
the dissecting-room and the dead-house at the same time that they were 
pursuing the course in practical obstetrics. In the midwives' clinic, on 
the other hand, the mortality seldom exceeded 3 per cent. Prolonged 
labor in the students' clinic was almost uniformly followed by death; 
while in the midwives' clinic the length of the labor made little differ- 
ence in the death-rate. Semmelweis had also observed that women 
delivered before admission and unattended wholly escaped the fatal 
fever. While pursuing these observations one of his associates, Professor 
Kolletschka, died from a dissection wound. The similarity of his col- 
league's symptoms to those presented by the puerperal women dying of 
fever was apparent. It immediately dawned, upon Semmelweis that the 
cause of the fatal malady in the lying-in service was the same as that 
which had resulted in the death of his colleague. Acting on this belief, 
he required the students to wash their hands in chlorine water before 
making internal examinations, and he restricted the number of such 
examinations. The death-rate immediately fell, and in little more than 



22s PHYSIOLOGY OF LABOR. 

a year it had been reduced to less than 2 percent. Thus was established 

the first Btep toward one of the mosl important of modern surreal dis- 
coveries. 

Antiseptic Agents. 

Mechanical Cleansing. Not the least important part of the antiseptic 
technique is the mechanical cleansing. This removes the greater part of 

the offending material. A well-polished instrument may be rendered 
almost sterile to culture tests by prolonged brushing with soap and hot 
water, and finally washing well with sterilized water. For the operation- 
tield and for the hands and arms of the operator the mechanical part of 
the process is doubly necessary, since the removal of surface epithelium 
and sebaceous matter not only carries with it the greater part of the 
offending material, but it is essential to the action of the chemical anti- 
septics. Freed from fatty matter and well wet by the soap-and-water 
scrubbing, the skin readily absorbs the antiseptic solution. 

Heat is at once the most generally available and the most reliable 
germicide; either dry or moist heat may be used. Moist heat is much 
the more effective. 

Dry Heat. Exposure for three hours to a temperature of 140° C. 
(284° F.) kills all pathogenic organisms and their spores. A special 
apparatus may be employed or the oven of a cooking-range can be util- 
ized. A thermometer capable of registering 148° C. (300° F.) or more 
must be used for regulating the temperature. Dressings, however, are 
penetrated by hot air only very slowly, and the method is, therefore, 
inadvisable for such material. It may serve for utensils capable of with- 
standing prolonged baking without injury, but the length of time required 
renders it unsuitable for general use. 

Moist Heat is employed in the form of steam and of boiling water. 

Steam is effectual at a temperature of 100° C. (212° F.) when in 
motion. Superheated steam partakes of the disadvantages of hot air, 
and moist steam acts to the best advantage only as flowing steam. Expo- 
sure for thirty minutes to flowing steam at 100° C. is almost absolutely 
reliable. In institutions steam sterilizing is now generally practised under 
a pressure of fifteen pounds, 121° C. (250° F.) or more, by means of an 
autoclave. Special provision is made to secure penetration. 

Numerous forms of steam sterilizers are to be had. A cheap and con- 
venient apparatus for the purpose is the Arnold steam sterilizer, or one 
of its modifications. For convenience in handling, instruments are best 
kept in a wire basket or in a folded towel during exposure in the steam 
chamber. They should be removed from the chamber immediately it is 
opened; otherwise polished steel surfaces are likely to become tarnished 
by the condensed steam which is deposited upon them on the admission of 
cool air to the steam chamber. 

Boiling for five minutes in water kills all pathogenic organisms likely 
to be encountered and their spores. One of the most effective of all 
practicable methods of using heat is boiling for five or ten minutes in a 
1 per cent, solution of sodium carbonate or bicarbonate. Articles so 
treated are sterilized within a few seconds. Even the most resistant 
spores are destroyed in less than five minutes. The addition of the 
soda has the further advantage that it protects metallic instruments from 



THE MANAGEMENT OF NORMAL LABOR. 229 

tarnishing, and it removes fatty matter. For instruments it is desirable 
that the soda be chemically pure, since the impurities in the commercial 
article may cause corrosion. A fish-boiler or a wash-boiler may be 
utilized in the absence of a special sterilizing apparatus. 

Chemical Antisepsis. Among the most useful chemical germicides may 
be mentioned the mercuric chloride or iodide and carbolic acid. Creolin, 
lysol, and a multitude of other antiseptics more or less extensively used 
by obstetricians offer little or no special advantage. Chlorinated soda 
solution, peroxide of hydrogen, 3 per cent, solution, and iodine water 
have the merit of being non-toxic. 

Mercuric chloride is decomposed in the presence of alkalies or of albu- 
min. In contact with the former the mercury is precipitated in the form 
of an oxide, and in the presence of the latter an albuminate of mercury 
is formed. A plain sublimate solution, therefore, soon becomes inert if 
mixed with bloody fluids. To prevent these changes, solutions of the 
bichloride of mercury for antiseptic use are acidulated with five parts 
of tartaric, acetic, or hydrochloric acid to one of the mercurial. The 
biniodide of mercury, on the other hand, yields a precipitate with albumin 
in acid, but not in neutral or alkaline solutions. The addition, however, 
of an equal weight of potassic iodide is required to render it freely solu- 
ble. These two mercuric salts are equally active as germicides, or nearly 
so, in solutions of equal strength. The strengths most commonly em- 
ployed are from 1 : 5000 to 1 : 500. 

The following formulas represent some of the antiseptic solutions used 
in obstetric practice: 

Mercuric Chloride (Sublimate) Solution, 1 : 2000. 

Bichloride of mercury Gr. yijss. 

Tartaric acid Gr. xl. 

Sterilized water Oij. 

Mercuric Iodide Solution, 1 : 2000. 

Biniodide of mercury ) . . 

Potassic iodide J aa Gr. vijss. 



Sterilized water 



Oij. 



Chlorinated Soda Solution, 1 : 10. 

Labarraque's solution w 

Sterilized water 3i x% 

Creolin Solution, 1 : 100. 

Creolin gijg. 

Sterilized water Oij. 



Carbolic Solution, 1 : 20. 



Carbolic acid 



Glycerin giii 

Sterilized water Oij. 

Convenience and accuracy in the employment of the mercurial anti- 
septics are promoted by the use of tablets containing the required chemi- 
cal ingredients. 

The peroxide of hydrogen solution may be used plain or diluted with 
two to four volumes of sterilized water; iodine, tincture, in 2 per cent, 
strength. 



230 PHYSIOLOGY OF LABOR 



Choice of Methods. 



Since sterilization by exposure to the action of chemical solution- is 
uncertain and often imperfect, the latter should be reserved for uses to 
which heat in not applicable. 

Boiling, Bteaming, or even hot air should be preferred for instruments, 
utensils, or dressings which are not liable to be injured thereby. A 
supply of towels, cheese-cloths for sponging, the vulvar dressings, and 
the Ligature for the umbilical cord should be sterilized by the nurse at 
the beginning of labor. They are first wrapped in a towel which is 
pinned securely, and in this they are kept after sterilizing till they 
are wanted for use. Obstetric forceps, needle forceps, needles, and scis- 
sors are wrapped in like manner and boiled for five minutes in water or, 
better, in the soda solution. 

The Obstetrician. 

Of first importance is the asepsis of the hands. The finger-nails are 
kept cut short. A hand-brush, soft soap, and a supply of the required 
chemical antiseptics are essential parts of the obstetrician's armamenta- 
rium. Soap may be conveniently carried in collapsible metal tubes. 
The chemical agents are carried in tablets or in the form of powders. 
The soap may be sterilized by heating to 100° C, and the hand-brushes 
by boiling in the soda solution. 

Cleansing the Hands. 

The hands and forearms are prepared by one of the following methods 
before contact with the genitals of the lying-in patient : 

Furbringer Method — Modified. 

(a) They are scrubbed systematically for five minutes with soap 
and hot water and a hand-brush. The water is used as hot as can 
be borne. Special attention must be given to the finger-tips and the 
subungual spaces. As Kelly has pointed out, the strongly alkaline 
soapy water cleanses better than running water or water frequently 
changed. A thorough rinsing in plain sterilized water completes this 
step in the process. 

(6) The nails are then cleaned with a nail-cleaner and again brushed 
in sterile water. The instrument should not be sharp, but should, rather, 
have moderately blunt edges which leave the surface of the nails smooth 
and polished. A piece of soft wood sharpened to a blunt point is a good 
substitute for the usual toilet article. It is made aseptic by boiling or 
steaming before using. 

(c) Finally, the hands and forearms are immersed for five minutes in a 
1 : 2000 mercuric chloride or iodide solution. Brushing with a stiff brush 
which has been reserved for the mercurial solution helps the thorough- 
ness of the disinfection. 

It is a distinct gain to saturate the skin for a minute with alcohol 
before immersion in the antiseptic solution. The alcohol should be of 
not less than 80 per cent, strength. This acts in some degree as a solvent 



THE MANAGEMENT OF NORMAL LABOR. 231 

for sebaceous material that may have escaped the soap-and-water cleans- 
ing, and it dehydrates the surface skin, thus permitting the antiseptic to 
sink more deeply. 

Permanganate Method. 

Steps (a) and (6) are carried out as in the preceding method. 

The hands and forearms are then immersed for five minutes in a satu- 
rated solution of potassium permanganate in hot sterilized water. Vigor- 
ous friction is applied with a sterile brush or with a piece of cheesecloth 
till the skin is stained a deep mahogany-brown. 

The hands and forearms are now held in a saturated solution of oxalic 
acid in sterile hot water till the brown stain is completely discharged. 

Lastly, they are immersed for three minutes in a 1 : 500 mercurial 
solution. 

Chlorinated Soda Method. 

Steps (a) and (6) are the same as before. 

The hands and forearms are then covered with a paste made by wetting 
chlorinated lime with water. They are next rubbed with a lump of 
crystallized sodic carbonate (washing soda) till a sensation of cold is felt. 
This yields chlorinated soda in its nascent state, which is the active dis- 
infectant. Friction is now applied with a hand-brush for five minutes. 

The chemical is washed off with sterilized water and the hands are 
rinsed with alcohol or with weak ammonia water. 

By the permanganate or the chlorinated soda process the hands may 
usually be rendered practically sterile. Yet recent observations seem to 
show that absolute disinfection is impossible immediately after infection 
by virulent exposures. 

Precautions. 

After cleansing the hands care must constantly be observed to prevent 
reinfecting them. Contact of the hands with any object that is not 
aseptic must be scrupulously avoided. Keeping the hands wet with 
glycerin containing a grain to the ounce of one of the usual mercurial 
salts favors continuous disinfection and helps to keep the skin soft. 
The glycerin should have been sterilized by heat. 

Operating Suit. During actual attendance on the patient the obstetri- 
cian wears a freshly sterilized operating gown, or he may prefer a coat 
and trousers of white duck or linen, to be worn over his usual clothing. 

Lubricants. For digital examinations within the passages no lubricant 
is required, as a rule. It is generally sufficient that the fingers be wet 
with the antiseptic solution. Should any other lubrication be required, 
as, for example, when the hand is to be introduced within the vagina, 
the back of the hand may be smeared with glycerin or with vaseline 
which has been heated for ten minutes to 100° C. 

Boiled Gloves. Should the physician be called upon to attend a labor 
directly after septic contact or when scant time is allowed for rigorous 
disinfection, he may wear lisle thread, or, better, rubber gloves which 
have been sterilized by boiling or steaming. Lacking these, such manip- 
ulations as are required during the perineal stage of natural labor may 
safely be conducted through the intervention of an aseptic towel. In 
a considerable proportion of cases it is possible to manage the labor, if 



232 PHYSIOLOGY OF LABOR. 

need be, without direct contact of the hands with the field of the obstetric 
wounds. The experiences of Kelly and of Zweifel have shown that DO 
method of skin sterilizing can be fully trusted directly after exposure to 
an acute infectious process. 

The Nurse. 

It is scarcely necessary to say that the nurse must be no less careful 
in all particulars than the doctor is required to be in the observance 
of antiseptic details. Her clothing must be scrupulously clean, and 
she should wear wash-dresses. As an extra precaution she must 
refrain from attendance on obstetric patients for a week or more after 
a septic exposure. During that time her hands and forearms are to 
be sterilized repeatedly, and she should take two or three full baths, 
with special pains to cleanse the hair. In all cases the nurse makes 
an entire change of clothing on taking charge of a patient in labor. 

The Patient. 

The aseptic preparation of the obstetric patient ought to begin weeks 
before the labor. She is to be taught the importance of daily bathing 
and of strict cleanliness of the external genitals and the adjacent skin 
surfaces. Diseased conditions of the rectum, the vulva, or the bladder 
should, as far as possible, be relieved. The character of the vaginal 
discharge should be learned in the antepartum examination. Discharges 
which are copious, which are yellowish or greenish, which excoriate the 
skin or are ill-odored, call for treatment of the diseased vagina. Douch- 
ing twice daily for two or three weeks with a 1 : 5000 bichloride solution, 
or with a 2 per cent, lactic-acid solution, is usually attended with marked 
improvement. The mercurial is to be followed immediately with a 
plain sterilized-water injection to prevent absorption of the chemical. 
It is advisable that all interference within the vagina cease at least three 
days before the labor, if possible. 

In health the vaginal secretion of the pregnant woman is germicidal, 
and in normal conditions, therefore, no antepartum douching is permis- 
sible. Irrigation is not only useless, but by washing away the vaginal 
secretion and by impairing the secretory activity of the vaginal walls it 
disturbs the natural protective agencies against sepsis. 

At the beginning of labor the nurse is instructed to give the patient a 
full bath and a change of linen. The lower bowel is emptied by an 
enema and well washed out. 

The external genitals and the entire lower half of body are rendered 
aseptic. The vulvar hair is clipped short, and finally a sterile compress 
saturated with a mild antiseptic, like boric acid or Thiersch's solution, is 
applied over the vulva. This is worn during the first and second stages 
of labor. In hospitals the lower extremities are usually enveloped in 
sterile coverings, and the table or bed on which the delivery takes place 
is dressed with steam-sterilized sheets. 

The Lying-in Chamber. 

If practicable a large well-ventilated room with a sunny exposure 
should be selected for the lying-in chamber. It is essential that the air 



THE MANAGEMENT OF NORMAL LABOR. 233 

be frequently renewed and be not exposed to contamination by reason 
of defective plumbing, or other avoidable sources of impurity. An open 
fire in suitable weather aids in maintaining the supply of fresh air. 
The recent presence of septic disease in the room renders it obviously 
unsuitable. It is well to have the hangings cleansed and the entire room 
freed from accumulated dust a few days before the labor. It is not 
necessary that the room be stripped of its usual furnishings, provided 
they are clean. A small table for holding instruments, sterilizing- 
basins, hand-brushes, etc., should be available. Should an operating- 
table be required in case of artificial delivery, the usual kitchen-table is 
suitable. 

Nurse's Preparations. The nurse has ready, in advance of the labor, a 
dozen towels and a half-dozen or more bed-sheets, two rubber sheets, 
large enough to cover the entire width and the greater part of the length 
of the bed. A labor pad, consisting of a square sack of cheese-cloth 
filled with surgical cotton or other absorbent material, should be pro- 
vided. It is to be placed under the patient during labor as a convenient 
dressing for taking up the discharges. This is made three or four inches 
thick and three feet square. Instead of this, a Kelly rubber pad, such 
as is commonly used in gynecological work, may be employed. Two 
dozen lochial guards should be prepared. They are made of the same 
material as the labor pad, and about two inches thick, four inches wide, 
and ten inches long. Tail-pieces are attached at each end for fastening 
to the abdominal binder. In the absence of these, folded napkins may 
be used as vulvar dressings. Scissors for dividing, and narrow linen 
bobbin or other suitable material for ligating, the cord are provided. 
All these things are wrapped in several packages, sterilized, and not 
opened till required for use. The nurse also has ready a hand-basin 
with soap and water, another for the antiseptic solution, two new hand- 
brushes, and glycerin or vaseline as a lubricant. These, too, must be 
sterile. 

In hospital practice the patient's linen and the bed linen are steam 
sterilized at the beginning of labor. Similar precautions are to be en- 
forced as far as practicable in home confinements. Usually in the 
latter class of cases it must suffice that the linen be fresh laundered. 
When complete asepsis is impracticable the nearest approach to it that 
may be possible under the circumstances is imperative. The nurse 
should be provided with antiseptics for use during the puerperium. 

Preparation of the Bed. In family practice the patient is usually con- 
fined on a bed, or a separate cot is provided, the woman being transferred 
to the bed at the close of labor. In hospitals a table is employed for 
artificial deliveries, and this should be the rule in private practice. To 
protect the bed from soiling by the discharges, it is covered with a rubber 
sheet. Over this is spread a muslin sheet, and both are piuned fast to 
the mattress. A second rubber sheet may be spread over these, and that 
overlaid with a muslin sheet. The latter are removed at the close of 
labor, and the remaining rubber sheet after five or six days. When econ- 
omy requires, table oilcloth may be substituted for the rubber. 

For convenience the cot or bed should be so placed as to be easily 
accessible from both sides. 



234 PHT8I0L00Y OF LABOR. 

M LNAGEMENT OF LABOB. 

Management of the First Stage of Labor. 

Examination During Labor. 

Preparation of the Patient. The antiseptic preparation of the patient 
has already been considered. At the onset of labor the lower bowel 
[g to be cleared and well washed out with an enema. If the first Btage 
is prolonged the rectal injection may be once or twice repeated. Until 
the second stage begins the woman, as a rule, need not be confined to 
the bed. The progress of labor is promoted by the upright position. 
Yet too much walking may be inadvisable before the head engages in 
the pelvic brim. It may favor prolapse of an arm or the cord. 

Diagnostic Signs of Beginning Labor. Precursory signs of labor are 
frequently observed for ten days or two weeks before active pains begin. 
First to attract the attention of the patient is the lightening. This gen- 
erally precedes the labor by ten days or a little more. The uterus sinks 
more deeply in the pelvis and the waist line becomes smaller. Light- 
ening, however, is not constant. At the same time the pressure of the 
uterus on the pelvic viscera is increased, and bowel movements and evacu- 
ations of the bladder occur more frequently. Irritability of the bladder 
and the rectum become still more marked when labor begins. The 
vaginal secretion grows freer as labor is established, and the mucous 
plug is expelled from the cervix in the form of a gelatinous mass. A 
slight discharge of blood or of blood-stained mucus, the show, may be 
observed. Yet the show and the expulsion of the mucous plug are not 
always noted. Inquiry should be made with reference to the frequency, 
strength, and duration of the pains and the time when they began. 

Most significant of actual labor are rhythmic uterine pains, with evi- 
dence of uterine contraction during the pains as elicited with the hand 
on the abdomen over the uterus. 

Abdominal Examination. The general plan and method of the abdom- 
inal examination during labor is substantially the same as in the ante- 
partum examination. The size of the foetal head should be estimated as 
accurately as possible by palpation, or by measurement with the pelvi- 
meter through the abdominal wall and by observing how far it sinks into 
the pelvic brim or can be made to do so by suprapubic pressure. The 
stage of progress can be determined approximately in the abdominal 
examination by noting how deeply the head has sunk into the true pelvis. 
When the head has not yet engaged, if the membranes are still unbroken, 
it can usually be pressed up out of the excavation by placing the hands 
on the abdomen over the sides of the head and sinking the finger-tips 
into the pelvic brim. After engagement of the head the relation of the 
base of the skull to the pelvic inlet is made out by deep palpation above 
the pubes. The height of the anterior shoulder, too, is learned by pal- 
pation, and it helps in deciding how far the head has descended. 

The signs of a possible face presentation should be looked for in the 
abdominal examination during labor. The extension of the head which 
causes the face to preseut develops only after the pains begin. 



THE MANAGEMENT OF NORMAL LABOR. 235 

The rate and force of the foetal heart are to be noted and to be listened 
for at intervals throughout the labor. A foetal pulse below 120 or above 
150 to the minute is a probable indication of danger to the child. A 
distended bladder presents a tense fluid tumor between the uterus and the 
lower part of the abdominal wall. It is readily recognized by palpation 
over the suprapubic region. 

Vaginal »Examination. Before examining internally the hands must be 
rendered aseptic. This part of the examination aims to determine the 
condition of the vulva, the vagina, the cervix, and the bony pelvis, and 
to verify the diagnosis of foetal presentation and position as made out by 
the abdominal examination. Possible anomalies, too, of the foetus that 
may complicate the labor should be recognized. 

The resistance likely to be offered at the vulva as the head descends, 
the lubrication of the vagina, the degree of dilatation of the cervix, the 
thickness and consistence of the cervical border, the presence or absence 
of injuries sustained in former labors are to be noted. 

For the internal examination the patient lies on the back with the 
knees drawn up. The examiner separates the labia with the thumb and 
fingers of one hand and introduces the examining fingers of the other 
hand into the vagina. 

Vertex presentation is recognized by the hard and globular character 
of the cranial portion of the foetal head and by the presence of sutures 
and fontanelles. 

The position is made out by locating the sagittal suture and learning 
which end is forward, or by finding in which quadrant of the pelvis the 
smaller fontanelle lies. It is not always practicable to reach the large 
fontanelle. Great care is required to identify the anatomical landmarks 
of the presenting part, especially when they are obscured by oedematous 
swelling. Every accessible part of the presenting pole should be searched 
with the examining fingers, using firm pressure. For the diagnostic signs 
of other than vertex presentation the reader must be referred to the chap- 
ters treating of those presentations. 

Prognosis. Definite predictions as to the duration of the labor are 
seldom possible. Conditions which determine the prognosis are the rela- 
tive size of head and pelvis, the hardness of the head, the degree of 
descent, the thinness and softness of the cervix, the presence or absence 
of complications, and the strength and efficiency of the pains. But it 
is impossible to foretell with certainty the character of the pains. Yet 
the patient is entitled to such assurance and encouragement as can reason- 
ably be given. 

Patient to Remain Out of Bed. As a rule, the patient should not be 
confined to bed during the first stage. She is usually allowed the liberty 
of the room. Much walking may hinder the engagement of the head, 
and is not advisable before the head has sunk into the excavation. A 
slow labor will be accelerated by moving about and even by the standing 
or sitting position; in over-rapid labor the woman should maintain a 
reclining posture on the bed or couch. The course pursued must be 
determined by the circumstances of the individual case. 

Frequency of Vaginal Examinations. A properly conducted internal 
examination with surgically clean fingers entails practically no risk of 
infection. Yet abundant statistics have shown that the best puerperal 



236 PHYSIOLOGY OF LABOR. 

results are obtained when it is possible to refrain wholly from internal 
interference. All unnecessary manipulations within the passages should 

he avoided. If a thorough antepartum examination has been made a 

single vagina] examination during the first Stage of labor will usually 
BUmoe. This is generally advisable, to make sure that the cord or an 
arm has not prolapsed and that no other complication has developed. 
Should any irregularity occur repeated examination- may be required. 

General Rules. In the absence of complications the attendance of the 
physician during the first stage of labor is not required, except in so far 
as is necessary to keep him advised of the rate of progress. Except in 
very slow labor the physician onght to be present in the house from 
the time the dilatation of the cervix is nearly complete. Unnecessary 
manipulation of the cervix is especially to be avoided. It impairs the 
local resistance against infection. Lifting the anterior portion of the 
cervix over the occiput is permissible only when the anterior lip retards 
abnormally the progress of labor. Light food can be allowed during 
the first stage. Pain, if severe, may be relieved by chloral. From 45 
to 60 grains may be given in doses of 15 grains every fifteen minutes in 
plenty of water. 

Management of the Second Stage of Labor. 

The management of physiological labor in the second stage, as in the 
first, should be mainly expectant. So long as all is normal the role of 
the obstetrician is little more than that of a passive observer. 

From the time the second stage is about to begin the patient must be 
in bed, and she must not, as a rule, be permitted to leave it even for 
evacuations of the bladder or the bowels. She is to be dressed in her 
usual night clothing, which is turned up and pinned at the shoulders to 
protect it from soiling. For still further protection of the patient's 
linen, the lower half of the body may be covered with a folded sheet 
fastened at the waist like a skirt. 

A slow labor may be accelerated or an over-rapid labor retarded, 
when possible by resort to simple measures. Inefficient pains are to be 
reinforced by summoning the aid of the abdominal muscles. Encourage 
the patient to hold the breath and bear down as the pain reaches its 
height. She may now and then assume a sitting posture on the edge of 
the bed. Bracing the feet and pulling upon the hands of a bystander 
or on a sheet-sling help the expulsive efforts. The sling is made by 
folding a sheet at diagonally opposite corners and twisting it loosely into 
a rope. One end is fastened at the foot of the bed and the patient pulls 
at the other. Sometimes a moderately firm abdominal binder may be 
useful. 

In too rapid labor the foregoing measures must be withheld and the 
pains retarded if necessary by the use of chloroform. 

Obstetric Positions. The choice of position in the expulsive stage of 
labor is usually left to the patient. Her comfort is promoted and the 
pains are stimulated by occasional changes of posture. For internal 
examinations either the lateral or the dorsal position may be chosen. 
The latter is generally preferred. A semi-recumbent or a sitting posture 
favors the pains owing to the influence of gravity. 



THE MANAGEMENT OF NORMAL LAB OB. 



237 



Walcher's Position. By reason of the nutation of the sacrum the 
antero-posterior diameters of the pelvic inlet are slightly increased when 
the woman lies on the back with the thighs hanging in extreme extension 
over the edge of the bed or table. (Plate XI.) Advantage may be taken 
of this fact, especially in difficult labor, while the head is passing the 
brim. At the outlet of the pelvis, on the other hand, the sacro-pubic 
diameter is perceptibly increased when the thighs are strongly flexed on 
the abdomen. For this reason, as well as for convenience in managing 
the birth of the head, the lateral position with the knees drawn up is 
usually to be preferred from the time the head approaches the pelvic 
outlet. 

Vaginal Examinations. In strictly normal labor there is little occasion 
to examine internally after the second stage is established, except for 
observing the rate of progress. With practice even the degree of descent 
can be learned almost as surely and as readily by external palpation, 
and vaginal examinations can, in simple labor, be omitted. By palpa- 



FlG. 204. 




Instrumental puncture of the membranes. (Ribemont-Dessaignes and Lepage.) 



ting over the suprapubic region the head can be made out till it has sunk 
deeply in the excavation. The occiput from the time it has reached the 
outlet of the bony pelvis can be felt by deep pressure with one or two 
fingers applied externally over the pelvic floor. While there is practi- 
cally no danger of infection in the vaginal examination conducted under 
proper aseptic precautions, yet the best puerperal results, as already 
stated, are obtained when no internal interference is practised. Should 
the labor be unduly prolonged or be otherwise abnormal, repeated in- 
ternal examinations may be required to determine the cause. 

Rupture of the Membranes. The bag of membranes usually breaks 
spontaneously by the time dilatation is complete, frequently earlier. 



PHYSIOLOGY OF LABOR. 

Sometimes it gives way at the onset of labor. In normal labor after 
the protruding bag has reached the pelvic floor, it no longer serves any 
useful purpose. If it -till persists it should be ruptured artificially. 
Usually this may he done with the finger-nail while the sac of waters IS 
tense during a pain. This failing, a sharp-pointed scissors, a straightened 
hairpin, or other suitable perforator, may be used. The instrument is 
sterilized and passed with its point resting on the finger-tip as a guard 
and a guide (Fig. _?<>4.) A mere prick suffices, the membranes tearing 
readily when once punctured. 

Obstetric Anaesthesia. In obstetric as distinguished from surgical anaes- 
thesia, the object is to blunt, not wholly to abolish the sensibilities. The 
use of anaesthetics for this purpose in labor is justified on both humanita- 
rian and scientific grounds. It is not only the plain duty of the obstet- 
riciau to relieve the needless sufferings of his patient, but the judicious 
employment of anaesthetic agents spares her unnecessary exhaustion. It 
must not be forgotten, however, that the prolonged or too free use of 
anaesthetics is capable of harm. When pushed beyond the stage of mere 
analgesia they lessen the strength and frequency of the uterine contrac- 
tions. While seldom causing death, they are not infrequently contrib- 
uting factors in the fatal issue. Doubtless the abuse of anaesthetics may 
be a predisposing cause of sepsis. They should be withheld so long as 
the pains are well borne without them. They are more especially called 
for in the latter part of the expulsive stage of labor. At the acme of 
expulsion the anaesthetic should, as a rule, be pushed to the surgical 
degree. 

Choice of Anaesthetics. For mere obstetric analgesia chloroform is gen- 
erally preferred. It has the advantage over ether that it is pleasanter; 
the necessary quantity, too, is less bulky, and is, consequently, more con- 
veniently carried in the obstetric bag. On the other hand, it is not so safe 
as ether, and possibly it impairs the strength of the uterine contractions 
more than does the latter agent. It is a powerful vasomotor depressant 
and its too free use may paralyze the arteries and incapacitate the heart. 
Theoretically it is especially dangerous in the third stage of labor. 

For obstetric operations in which full narcosis is required, chloroform, 
as a rule, gives place to ether. By some obstetricians the latter anaes- 
thetic is preferred for general obstetric use. It is no less manageable 
than chloroform for all obstetric purposes, and, as its advocates believe, 
it does not weaken, but rather stimulates, the uterine contractions. 
The Schleich mixture may prove useful for anaesthesia, either of the 
obstetric or the surgical degree, but no experience with it as an anaes- 
thetic for the lying-in room has thus far been reported. 

In the presence of bronchitis, ether is unsuitable, owing to its irritant 
effect on the respiratory mucous membranes. In atheromatous disease it 
is dangerous, since it increases the vascular tension. Chloroform is to be 
preferred in eclampsia and in tetanic contraction of the uterus. 

Method of Administration. In obstetric anaesthesia the anaesthetic may 
be given by a competent nurse under direction of the physician. Nar- 
cosis to the surgical degree for operative interference ought to be trusted 
only to a skilled medical assistant. It is desirable that the patient shall 
have taken no solid food for several hours before anaesthesia, especially if 
the narcosis is to be carried to the surgical degree. The head is lowered 



THE MANAGEMENT OF NORMAL LABOR. 



239 



to the level of the body, particularly if chloroform is to be given, all 
constricting bands of clothing are loosened, and the region of the mouth 
and nose smeared with glycerin. The patient is requested to remove false 
teeth or other foreign bodies from the mouth. The heart is examined; yet 
the presence of cardiac disease does not necessarily forbid the use of anaes- 
thetics. Usually the shock of difficult labor, and especially of operative 
interference, is more dangerous without than with the anesthetic. Yet 
a weak heart calls for special caution in the use of these agents. 

Mode of Administration. For ordinary obstetric anaesthesia a coarse 
towel is a good inhaler. It is placed over the patient's face aud held by 
the middle, which is lifted six or seven inches from the face. (Fig. 205.) 



Fig. 205. 




Giving chloroform with the towel-inhaler and dropping-bottle. 

A large cone-shaped air-chamber is thus formed which ensures ample 
dilution of the anaesthetic vapor. Instead of this an Esmarch mask 
or an Allis inhaler may be used. The anaesthetic is dropped upon the 
inhaler opposite the patient's mouth and nose. Except when complete 
narcosis is desired it is given only with the pains. To develop its effect 
by the time it is most needed, when the pain has reached its height, the 
inhalation must begin promptly at the beginning of the pain. If chlo- 
roform is used only a single drop is let fall on the inhaler with each 
breath. If ether is employed three or four drops will be required at 



240 PHYSIOLOGY OF LABOR. 

cadi Inspiration. To increase the effect «>f the drug, if necessary, ask the 
patient to breathe rapidly as the inhalation begins. Tin* administration 
ia stopped l>v removing the inhaler as sood as the pain begins to subside. 

The drop-by-drop method should be insisted upon for cither obstetric 
or surgical anaesthesia. It insures at once the greatest possible safety 
and the least discomfort in the use of either chloroform or ether. 

At the acme of expulsion, as the head is passing the introitus, the 
anaesthesia should generally he pushed to full unconsciousness. This 
not only spares the woman the severer pangs of labor, but by retarding 
expulsion and by relaxing the muscular structures of the pelvic floor it 
tends to prevent lacerations at the vulvar outlet. 

Complete amesthesia when required for obstetrie operations during the 
birth or at its close is to be managed in accordance with the well-estab- 
lished rules of surgical practice. 

The Perineal Stage of Labor. The management of labor at the acme 
of expulsion is chiefly concerned with the prevention of injuries to the 
pelvic floor. Normally the soft parts at the vulvo-vaginal outlet of the 
birth-canal yield without tearing under the gradual advance of the foetal 
head and escape important injury. Yet notable laceration of the pelvic 
floor occurs in about 35 per cent, of term labors in primiparse, and nearly 
a third as often in women who have been delivered before. Rupture of 
the fourchette is the rule, and is unimportant. Minor tears may occur at 
any part of the vulvo-vaginal ring. The more important lesions are 
those of the posterior segment of the pelvic floor near the median line. 

More or less extensive laceration is frequently unavoidable in foetal 
malposition, in narrow pelvis, in relatively small vaginal outlet, and in 
undue rigidity of the pelvic floor from defective development, oedema, 
or other causes. On the other hand, at least half the pelvic-floor in- 
juries occurring in general obstetric practice are preventable by skilful 
management of the perineal stage of labor. 

Prevention depends on the distensibility of the pelvic floor and the 
smallness of the engaging circumference of the foetal head. 

The relaxation of the floor is promoted by slow and gradual delivery 
of the head, permitting the structures to stretch. Over-rapid expul- 
sion frequently results in laceration. It is seldom that the head can 
safely be permitted to escape in first labors in less than twenty to forty 
minutes from the time the pelvic floor begins to bulge. Half this time 
may suffice in subsequent labors. 

The mechanism of expulsion must be so regulated that the smallest 
circumference of the head is constantly kept in the grasp of the resisting 
girdle. Moreover, the direction of expulsion must be controlled lest the 
soft parts be subjected to too great strain by misdirection of the driving 
force. 

From the time the head approaches the pelvic floor the labor is best 
managed with the patient lying on the side, especially in primiparas. The 
hips are brought close to the edge of the bed. The obstetrician stand- 
ing or sitting by the side of the bed has complete command of the rate 
and mechanism of expulsion. For some time before the occiput appears 
at the vulvar orifice the head can be felt without examining internally 
by pressing the fingers against the pelvic floor. The rapidity of descent 
may thus be watched till the occiput begins to protrude during the pains. 



THE MANAGEMENT OF NORMAL LABOR. 



241 



From this period, if not for a longer time, the parts should be under 
ocular inspection. The rate of descent is moderated by moderating the 
action of the abdominal muscles by the use of chloroform, and by direct 
pressure with the fingers held against the uncovered portion of the head. 
The head is permitted to descend only so far at each pain as can be done 
without exposing the tense structures to risk of tearing. The degree 
of tension is estimated by occasionally passing the finger just within the 
resisting vulvar ring at the height of a pain. 

To secure delivery by the smallest circumference of the head too rapid 
extension must be prevented. Keep its long axis in the axis of the 
outlet till the equator of the head has passed. To relieve the pelvic 
floor from undue strain by misdirection of the expelling force, press the 
head firmly up into the subpubic arch as it is about to escape. 



Fig. 206. 




Regulating birth of head. 



All this may be effected without pressure upon the pelvic floor. Yet 
no harm need be done by properly guarded pressure against the head 
through the floor. With the thumb laid along one side of the vulva 
and the fingers along the other, and the palm of the hand resting broadly 

16 



242 PHYSIOLOGY OF LABOR, 

over the perineum, the head can be carried well up into the subpubic 

Bpaee and the rate and mechanism of delivery be readily controlled. 

Yet it must be remembered that the object is not support of the floor but 

regulation of the head movements. 

F.n- the execution of any of the foregoing manipulations the operator 
may assume the position shown in Fig. 2()<J during the expulsion of the 
head. Sitting on the bed behind the patient, both hands are held upon 
the head, or one on the head and the other on the part of the pelvic floor 
which overlies the head. 

To protect the hands from soiling with fecal matter it is well to keep 
the anal orifice covered with an aseptic towel wet with the antiseptic 
solution during the manipulations required at the expulsion of the head. 
A basin containing the antiseptic solution should be placed near the bed. 
With a piece of sterile cheese-cloth dipped in the antiseptic, the protruding 
portion of the head and the surrounding perineal surfaces are cleansed as 
often as soiled by the discharges. 

Episiotomy. When extensive laceration at the vulvar outlet is other- 
wise inevitable incisions may be made on either side. Episiotomy substi- 
tutes for a posterior laceration, which is often difficult of complete re- 
pair, incisions through less important structures, which can be easily and 
perfectly closed by suture. The incisions are made about one-third way 
from the median line posteriorly when the parts are stretched during a 
pain. They should be about 7 cm., J inch, deep, and 2.5 cm., 1 inch, 
in length. 

It is needless to say that to be of service the episiotomy cuts must 
anticipate the tearing, yet the necessity for them cannot be determined, 
nor can they be properly effected till the parts are well stretched by the 
protruding head. 

During a pain a finger is passed within the vulva by the side of the 
head till a cord-like girdle can be felt. A blunt-pointed bistoury is then 
slipped flatwise between the head and the tense ring. Holding it in a 
line parallel with the long axis of the mother's body the edge is turned 
outward and the girdle is cut. The incision is repeated on the opposite 
side of the vulvo-vaginal orifice. Should the mistake be made of hold- 
ing the knife in the direction of the outlet of the soft parts, instead of 
the long axis of the mother's body, it will be found after delivery that 
the tip of the blade has invaded the median portion of the pelvic floor, 
incising the very structures which the operation was intended to save. 
A strong blunt-pointed scissors may be substituted for the bistoury if 
preferred. 

After delivery the incisions are sutured. This is easily effected with 
the patient on the back, or, better, on the side. In the latter posture the 
uppermost cut is sutured first. The field is thus unobscured by blood 
which drains from the vagina over the dependent side. The position is 
then reversed for closing the other incision. 

Management of the Birth of the Trunk. On birth of the head examina- 
tion is promptly made to learn if the cord is coiled about the neck. If 
it is, the loop or loops are drawn down successively over the head. 
Should the attempt fail, which can scarcely be possible, the cord is divided 
with scissors and the trunk at once extracted. The head is supported 
with the hand, in the axis of expulsion. The delivery of the trunk is left 



THE MANAGEMENT OF NORMAL LABOR. 



243 



to the natural forces unless reason appears for hastening the extraction. 
It is not advisable to drag the child unnecessarily from an uncontracted 
uterus. As a pain comes on a finger is hooked in the posterior axilla 
from behind . The shoulder is pressed forward toward the child* s sternum 
and is lifted, over the perineal edge while the anterior shoulder still rests 
behind the symphysis. The posterior arm is now extracted and the re- 
maining shoulder escapes under the pubic arch. When for any reason 
immediate delivery of the child by traction is required, the uterus should 
be stimulated to contract as the trunk is delivered, by friction with the 
hand over the abdomen. 

Management of the Third Stage of Labor. 

From the moment the head is born one hand of the obstetrician or assist- 
ant is held on the abdomen over the uterus. So long as the uterine con- 



Fig. 207. 




Manual expression of placenta. Method of Crede. (Beers.) 

tractions go on normally after the child is expelled, only light pressure 
and no friction or other manipulation is to be used. Should the uterus 
remain too much or too persistently relaxed, contraction may be stimu- 



244 PH TSIOLOQ Y OF LABOR. 

lated by gentle friction, moving the abdominal wall with the hand, slowly 

and in a circular direction, <>vcr the anterior wall <>f the uterus. If more 
active measures are called for to provoke contraction, the fundus may 

be grasped firmly with one or both hands. 

Crede's Method of Expressing the Placenta. The uterus is thus watched 
for hall an hour after the birth of the child. If by tins time the placenta 
has not been separated and expelled by the unaided contractions, resort is 
had to Crede's method of expression. This is practised as follows: The 
fundus IS grasped with the thumb in front and the fingers behind and a 
uterine contraction awaited. As the pain reaches its height the fundus 
is forcibly compressed witli the hand and at the same time forced gently 
downward in the pelvis. (Fig. 207.) The efficiency of the manipula- 
tion is greatly increased if the fundus is also crowded backward to bring 
the uterine more nearly in line with the vaginal axis. Should the first 
attempt fail it is repeated with each successive contraction till the after- 
birth is expelled from the uterus. 

If the placenta still remains in the vagina or lower uterine segment, 
it is drawn down by gentle traction on the cord. When it presents at 
the vulva it is caught with the hands and careful traction made to sepa- 
rate the membranes should they still be partially adherent. The uterus 
is to be watched with the hand over the abdomen for half an hour longer 
till retraction is fully established. Friction or more vigorous manipula- 
tion is applied from time to time only as required to maintain normal 
contractions. 

Examination of the Placenta and Membranes. On expulsion the mater- 
nal surface of the placenta is carefully examined to see that no fragment 
has been left behind. The membranes are also inspected to make sure 
that both amnion and chorion are complete. This is best done by trans- 
mitted light. As a matter of scientific interest, the weight, size, and 
shape of the placenta, the length of the cord, the site of the umbilical 
insertion, and the presence or absence of anomalies may be noted. 

Retraction of the Uterus. Should the uterus not retract promptly 
and firmly after the expulsion of the placenta, contractions are stimu- 
lated by friction with the hand on the abdomen. When more active 
measures are required, a half drachm of fluid extract of ergot may be 
given and repeated p. r. n. One or two doses of ergot are. generally 
advisable when the uterus remains much relaxed, and especially after 
chloroform anaesthesia. In small doses this agent is practically harmless, 
and it fulfils more than one important indication in the management of 
the final stage of labor. It is useful as a prophylactic, not only against 
hemorrhage but against sepsis. By maintaining contractions it tends to 
prevent the accumulation of blood-clots in the uterus, to lessen after- 
pains, and to close the avenues of absorption. By limiting the blood- 
supply it promotes involution. The uterus must be watched with the 
hand on the abdomen till retraction is complete. This will require the 
attention of the physician or nurse for not less than half an hour. 

Care of the Child. On birth of the head the nurse cleanses the face 
and especially the eyes of the child, the latter best with a saturated boric 
acid solution or other mild antiseptic. The eyes are carefully dried. 
This precaution is taken for the prevention of ophthalmia, and is doubly 
important should there be reason to suspect that the vaginal discharge 



THE MANAGEMENT OF NORMAL LABOR. 245 

is infectious. In hospital practice a drop of a 2 per cent, solution of 
silver nitrate, Crede's solution, is instilled into each eye of the child at 
birth. This rule may well be carried out in family practice, and is im- 
perative in the presence of a gonorrhceal, septic, or diphtheritic vaginal 
secretion. The application is harmless, and is almost an absolute pre- 
ventive of purulent conjunctivitis in the new-born. 

On the complete expulsion of the child steps should immediately be 
taken to fully establish the respiratory movements. Mucus in the pharynx 
may be removed with the finger wrapped with a soft wet piece of cheese- 
cloth. Still better is a soft rubber tube with a rubber bulb attached. The 
mucus is sucked up into the tube. Holding the child suspended by the 
feet favors drainage from the respiratory tract, should it contain liquor 
amnii or blood drawn iuto it by premature attempts at respiration. 

The contact of cool air with the moist surface of the body, as well as 
the air-hunger created by the partial interruption of the utero-placental 
circulation, usually excites respiratory movements. Directly after birth, 
should the child not promptly begin to breathe, the action of the respi- 
ratory muscles may be stimulated by gentle flagellation over the buttocks, 
by dashing a little cold water upon the face and chest, or by forcibly 
blowing upon the face. 

The treatment of asphyxia neonatorum will be considered in the 
chapter on Anomalies and Diseases of the New-born Infant. 

Ligation of the Cord. The ligation of the cord should, as a rule, be 
delayed till the child is breathing freely. The infant thus gains from 
one to three ounces of blood. This post-natal afflux of blood is due to 
the force of thoracic aspiration. While of comparatively little moment 
in robust infants, it is often a matter of vital consequence in premature, 
puny, and feeble children. 

The utmost aseptic care must be observed in ligating and dividing the 
cord. Fatal infection of the umbilical vessels may result from the neglect 
of proper cleanliness. Ligature and scissors, as well as the hands and 
everything that comes in contact with the umbilical stump, must be 
surgically clean. Before tying the cord the physician assures himself 
that no hernial protrusion has taken place into it. Firm pressure is 
applied with the thumb and fingers at the point to be ligated to press 
out the jelly of Wharton. This lessens the risk that hemorrhage may 
occur from loosening of the ligature by shrinkage of the stump. The 
ligature, which may be of narrow linen bobbin about a sixteenth inch in 
width, is then applied and tied tightly about three-fourths of an inch 
from the cutaneous junction. The cord is cut with scissors a quarter of 
an inch beyond the ligature. The end of the stump is pressed w T ith a 
sterile cheese-cloth to see if its bleeds; should it do so it is tied again. 
The maternal end of the cord need not, as a rule, be ligated. In case of 
twins the second ligature should not be omitted, lest the undelivered child 
perish from blood-loss should the placental circulations communicate. 

The child is wrapped warmly and laid in a warm place till the neces- 
sary attentions to the mother are completed. 

Examination of Mother and Child. The physician assures himself of 
the general condition of the mother, and especially of the pulse-rate, and 
again examines the uterus with the hand on the abdomen. A careful 
inspection is made of the vulvar orifice for possible lacerations. Notable 



246 PHYSIOLOGY OF LABOR, 

injuries should immediately be sutured. The method <>f suture will be 

found detailed iu the chapter 00 the Treatment of* Laceration-. 

The child is c iivfullv examined for the possible existence of develop- 
mental anomalies. 

Vulvar Dressing. The nurse cleanses all soiled portions of the mother's 
body, bathing the external genitals with an antiseptic solution, and re- 
moves all blood-stained linen from the patient and the bed. The vulva 
is covered with an aseptic napkin which is fastened behind and in front 
to the abdominal binder when the latter is applied. Instead of the napkin 
the special dressing already described may be used. These dressings 
are burnt after once using. Their object is to receive the discharges 
and, through frequent changing, to promote the cleanliness of the ex- 
ternal genitals. 

Abdominal Binder. A moderately firm bandage about the abdomen 
adds to the comfort of the patient after labor. It may be fairly tight 

Fig. 208 




Abdominal binder. 

for the first twelve hours for support. After that time it should be 
slightly looser. This is discarded by the time the woman leaves the bed 
or before. The binder is best made of strong unbleached muslin. It 
should be wide enough to reach from the great trochanters to the ensi- 
form appendage, and long enough to barely overlap after encircling the 
body. It is pinned with shield-pins in the median line in front, and 
then made tight by pinning a fold at each side. (Fig. 208.) If com- 
presses are used under the binder one should be placed above and one on 
each side of the uterus. 

Final Duties. Before leaving the physician again takes note of the 
condition of the mother, and examines the child to see that all is normal. 
The nurse is given full instructions with reference to the care of the 
mother and child. One or two doses of ergot and a prescription for 
relieving after-pains are left, to be used if required. 



PAET IV. 

PHYSIOLOGY OF THE PUERPERIUM 



CHAPTER X. 

THE PUERPERAL STATE. 

Definition. By the puerperal period is meant the time which elapses 
after childbirth during which the changes observed in the course of labor 
and pregnancy are being effaced and the body is returning more or less 
approximately to the state in which it was before impregnation. But, 
since these progressive and retrogressive alterations chiefly involve the 
generative organs, we may leave out of consideration the general consti- 
tutional changes, and for practical purposes limit our definition so that 
the puerperium may signify " that period after labor in which the geni- 
talia are regaining the condition proper to those of the non-gravid 
woman." In the case of women who have previously borne children, 
the condition reached at the end of the puerperium should, except as 
regards the inevitable local changes, be that observed before the last 
pregnancy. In the case of primiparse, the previous nulliparous condi- 
tion is never regained. Certain changes have taken place in the genitalia 
and in the abdominal walls which are permanent and which are accom- 
panied with more or less certain indications that at least one labor has 
occurred. 

The puerperium may, therefore, be said to begin immediately after the 
delivery of the placenta and to end with the complete involution and 
regeneration of the internal genitals. Exact anatomical observations 
have proved that the processes involved usually take about six weeks. 
Between individual cases the variations may be considerable. It is inter- 
esting to note that the limits of the period had been established long 
before our modern scientific methods of examination were known. It 
is not hard to see how the older obstetricians made so correct calculations. 
Experience had taught them that after six weeks the normal functions of 
the non-impregnated genitalia — namely, menstruation and conception — 
could begin again. It is true that in nursing women menstruation rarely 
occurs at so early a date, but it is a well-known fact that it is possible for 
them from this time forward to conceive again, the possibility becoming 
greater every month. 

Introductory Remarks. Pregnancy, labor, and the puerperal state are, 
under ordinary circumstances, natural processes, but in all of them the 
physiological borders so closely upon the pathological that it is extremely 
difficult to draw a hard-and-fast line between the two. Of necessity, 

(247) 



248 PHYSIOLOGY OF THE PUERPERIUM. 

then, in descriptions of the so-called normal puerperium and its man- 
agement, it fa almost impossible to avoid touching upon certain minor 

pathological conditions, which arc not severe enough to bring ahont anv 
Serious results. 

The puerperal woman bas been aptly compared to a person suffering 

from a recent more or less severe wound. Provided the patient has been 
in a normal condition previously, and that the wound be not too severe 
and can he kept surgically clean, beyond the weakness caused by pain, 
lose <>f blood, and a certain amount of nervous shock, there is nothing to 
interfere with a speedy recovery. But once allow infections material to 
enter the wound, a series of pathological processes ensue which materially 
alter the features of the case. In the puerperal woman we have to deal 
with open wounds extending over a large surface, a contused condition of 
the genitalia, exhaustion following labor, and a condition of more or less 
marked nervous shock. Here, then, we have a condition physiological, 
perhaps, but easily transformed into a most serious pathological state. 
Everything, it may be said, is present which would render the occurrence 
of infection peculiarly easy. The open wounds and contused surfaces offer 
a decreased local resistance; the lochia! discharge and the blood-clots in 
the uterine sinuses at the placental site form excellent media for bacterial 
growth. The very number of the small lacerations increases the chances 
that any poison introduced may find a congenial nidus where it can pro- 
duce a localized pathological process or from which it can spread and 
infect the whole system. Added to this we have the general weakness 
and exhaustion of the whole body, which offers decreased resistance to 
the attack of any pathogenic agent. Thus it will easily be seen that for 
the bringing about of a normal puerperium prophylactic measures play 
the most important part, and when complications arise after a normal 
labor the obstetrician has always to ask himself how far he has been 
responsible for their existence and in what way his technique has been 
faulty. Nothing can be more satisfactory to the physician than to see 
his patient who has just undergone perhaps the most severe trial and 
suffering which she has ever experienced, regaining almost perceptibly 
from hour to hour her former health and strength, and nothing is more 
painful to watch than the course of a puerperal infection, which if not 
fatal is always serious, and may leave behind it irreparable damage, 
especially when he has to confess that the cause for the whole trouble 
probably lies in some apparently trivial error, either of omission or com- 
mission, which has occurred in the course of what should be a physio- 
logical process. 

We shall now take up in detail the changes which take place in the 
genitalia during the puerperium. 

Outlet and Vagina. In primiparse the hymen and the fourchette are 
almost invariably torn, and such tears are of no import. Deeper lacera- 
tions, especially those extending into the perineal body or into the bowel, 
though at times not preventable, must always be considered as patholog- 
ical. The tear in the hymen is usually stellate, and after involution traces of 
the membrane are found in the small bodies surrounding the outlet, the so- 
called carunculse myrtiformes. The whole vagina has been dilated during 
labor, but, though in all cases microscopic lacerations probably occur, the 
elasticity of the tissues of the canal generally prevents the occurrence of 



THE PUERPERAL STATE. 249 

any serious injury. The external and internal parts, however, are always 
more or less contused, oedematous, and hyperemia Small lacerations usu- 
ally heal spontaneously, if kept clean. The more serious tears, when coap- 
tation of the wounded surfaces does not occur spontaneously, if neglected, 
heal chiefly by granulation and cicatrization, and may leave extensive 
areas of scar-tissue behind them. Lacerations in the anterior wall of the 
vagina may give rise to troublesome vesico-vaginal, urethro-vaginal, or 
even vesico-urethro-vaginal fistulae. A vesico-vaginal fistula at the site 
of the vesical trigone is an especially troublesome complication. Lacera- 
tions in the posterior vault and posterior wall may or may not commu- 
nicate with the peritoneal cavity or rectum. Superficial tears in this 
region are not unusual. An overstretching of the outlet or lacerations 
which have separated some of the fibres of the levator ani muscle are 
frequently found. Fortunately, in many cases it will happen that at the 
end of the puerperium nature has rectified this condition. But in not a 
few instances the function of the levator ani is permanently impaired. 
The anterior fibres of this muscle furnish the chief support of the outlet; 
acting from the two rami of the pubic bone they pull the vaginal orifice 
upward and forward away from the direct line of intra-abdominal press- 
ure. If, therefore, the function of these fibres be put in abeyance pro- 
lapse of the vaginal walls and descent or prolapse of the uterus must 
almost certainly follow. The treatment of serious tears or overstretching 
of this muscle has been discussed elsewhere. 

Normally the small tears of the vagina soon heal promptly, sometimes 
by first intention, despite their continuous lochial bath. More or less 
extensive cicatrices may be left behind to mark their previous situation. 
The vagina becomes smaller and narrower, and from being smooth be- 
comes wrinkled, though the rugae are never so deep or as well marked as 
in the primipara. The swollen, succulent, and hypersemic condition grad- 
ually subsides. Should there occur no unusual or pathological amount 
of cicatrization, the vagina at the end of the puerperium will be found 
roomier than in the primipara and somewhat shorter. The outlet will 
be considerably larger than before, but should be still held up closely 
under the pubic arch by the action of the levator-ani muscle and be 
capable of effective contraction and narrowing by the joint action of this 
muscle and of the constrictor cunni. The rima vulvae should be almost 
entirely closed. 

Uterus. The uterus as a whole immediately after labor is said to weigh 
from 800 to 1000 grammes. It measures from 15 to 20 cm. in length, 
and from 11 to 12 cm. in breadth at the level of the Fallopian tubes. 
The wall of the upper uterine segment measures 3 to 4 cm. in thickness. 
The uterine cavity (sound measurement) is 15 to 16 cm. in length. The 
following table shows the comparative measurements of virginal and 
multiparous uteri, made by Sappey, Bichet, and Henning: 





Virgin. 


Nullipara. 


Multipara 


Length of uterus 


. 5.8 cm. 


6.2 cm. 


6.8 cm. 


Width. 


. 3.8 " 


3.9 " 
2.3 " 


4.2 " 


Thickness 


. 2.1 " 


2.5 " 


Vertical diameter of cavity . 


. 4.5 " 


6.1 " 


Capacity of the uterus 




2 to 3 " 


3 to 5 " 


Length of entire organ in young 


women 


5.6 " 




Weight of virgin uterus . 


. 40 grammes 







250 PHYSIOLOGY OF THE PUEBPEEIUM. 

It will be seen from these figures that the parous is in all its dimen- 
sions somewhat larger than the virgin uterus. The cervical portion is 

also shorter than in the virginal condition. The arbor vitflB is partially 

effaced. The Bound measurements of the uterus during the puerperium, 
as given by Hansen, are as follows: 

Tenth (lav, 8 to L3.5 cm. 

Fifteenth" day, 8.3 to 11.5 cm. 

Third week, 7.5 to 10.5 cm. 

Fourth week, 7 to 9.3 cm. 

Fifth week, 6.5 to 9 cm. 

Sixth week, 6.12 to 9.1 cm. 

Eighth week, 5.6 to 8.5 cm. 

Tenth week, 5.4 to 7.5 cm. 

Immediately after the expulsion of the placenta the fundus of the 
litems should be felt as the upper extremity of a globular body half-way 
between the umbilicus and the upper border of the symphysis. In about 
six hours, however, it will be found to have risen again and to be about 
on a level with the umbilicus, or usually about 11 cm. above the sym- 
physis, the greatest breadth of the uterus at the time being about 
10 cm. From this time it diminishes rapidly in size, so that by the 
ninth, tenth, or twelfth day the fundus should be found at the level of 
the upper border of the symphysis, the body of the uterus lying entirely 
in the true pelvis. The uterus should at this time be somewhat ante- 
verted or anteflexed. Involution also goes on in the cervical canal and 
in the portio vaginalis. Immediately after birth the cervix hangs down 
into the vagina, as a thin, flaccid ring, in marked contrast to the firmly 
contracted uterine body above. Gradually the tissues regain their elas- 
ticity and the regenerated portio vaginalis contracts. At first the cer- 
vical canal measures 7 cm., but already on the second day contraction has 
begun. At the beginning of the second week the portio vaginalis has 
about regained its usual size and consistence. 

Uterine Muscular Tissue. During pregnancy the muscle cells are greatly 
increased in size, attaining from ten to twelve times their former length 
and from three to five times their normal breadth. Although the fact 
was formerly much disputed, it is now generally recognized that there is 
also a new formation of muscle cells. After labor, therefore, we have 
an enormous amount of tissue which disappears, the uterus losing in the 
first two weeks about a pound in weight. This takes place as a result 
of fatty degeneration. It is a well-known fact that if any organ or part 
of an organ in the body is deprived of nourishment it undergoes fatty 
degeneration and subsequently at least partial absorption. Now, the 
strong contractions of the uterus lessen the blood-supply, and by cutting 
off the nutrition cause the degeneration of the superabundant amount of 
tissue. It is clear, therefore, in the absence of sufficiently powerful con- 
tractions the uterus cannot reach, at least within the normal time, the 
appropriate state of involution. 

It is a disputed point whether or not these enlarged muscle cells totally 
disappear and are replaced by newly formed cells. Some authorities hold 
that the majority, if not all, of these large cells are entirely destroyed, 
and that the involuted uterus is made up of new cells. The weight of 
the evidence, however, seems to favor the view that the large cells undergo 



THE PUERPERAL STATE. 251 

degeneration only up to a certain point, and that the process then comes 
to a standstill, so that the atrophy ceases as soon as the cells have reached 
their original size. It is certain that they do not become quite as small 
as formerly, or if they do some of the newly formed cells must persist, 
since the parous uterus is always somewhat larger than that of the virgin. 

The connective tissue undergoes similar changes. 

Uterine Vessels and Nerves. The bloodvessels, lymphatics, and nerves 
have participated in the general growth during pregnancy, and have 
increased in length and diameter. The arteries have correspondingly 
thicker walls, except in the case of those which run in the decidua, where 
the walls are thinner than usual for vessels of so large a size. On 
account of their length they take a tortuous course, and many communi- 
cate directly with veins. At the placental site some of the sinuses have 
been closed by thrombi in the last month of pregnancy. Those which 
remain open till after delivery are closed by the contractions of the uterus, 
which bring their walls in close apposition, causing the formation of a 
clot, which later on undergoes organization. Other vessels of the uterus 
undergo pressure atrophy, and are finally obliterated, the obliteration in 
some cases being brought about by excessive growth of their walls. In 
examining sections of parous uteri, these vessels, with much thickened 
coats, are often met with and in many cases undoubtedly persist after 
the process of involution is finished. 

Uterine Mucosa. The mucosa, which measures only a few millimetres 
in thickness, may be divided for purpose of description into two layers. 
The inner, which is in contact with the decidua, is very poorly provided 
with glandular elements, and on section seems to be made up almost 
entirely of decidual cells with small round mononuclear cells resembling 
lymphocytes scattered through it. This has been termed the " cellular 
layer." The outer layer is composed entirely of convoluted glands, 
which give to the sections a honeycombed appearance. This layer is 
known as the u honeycomb " or " glandular " layer. The inner or 
cellular layer is for the most part thrown off along with the decidua. 
Of the outer or glandular layer, a portion remains behind, and from it 
the new mucosa or endothelium is formed. The process is strongly sug- 
gestive of one of transplantation. The tubes of the glands have retained 
their epithelium, so that we have, as it were, islands from which the regen- 
eration spreads, so that what at first was apparently a raw surface is 
gradually covered. The tissue which is not utilized in the process under- 
goes fatty degeneration and is gradually thrown off. 

Patches of pigment are found for a considerable time in the endome- 
trium, especially at the seat of the placenta, where they persist longer 
than elsewhere. The placental site is probably the last to receive its 
protecting coat of epithelium. This is doubtless due to peculiarities in 
the histological structure of the glandular layer at this point, very little 
trace of it being seen. 

By the end of the fifth or sixth week the new endometrium is probably 
complete. 

Tubes, Ovaries, and Parametrial Tissues. During pregnancy the tubes 
are elongated and somewhat thickened, the parametrial tissues are also 
hypertrophied, and all the adnexa are hypersemic. After delivery this 
hyperemia subsides and a physiological atrophy takes place until the 



252 PHYSIOLOGY OF THE PUEBPEBIUM. 

organs regain approximately their original size. The corpus luteum, 

which may be still present after labor, gradually shrivels, and as time 

goes on becomes more deeply embedded in the ovary until it finally dis- 
appears or can be demonstrated only by the microscope. 

Lochia. For the source of the lochia we have not far to look when we 
OOOsider that we are dealing with an extensive open wound and with the 

removal of a comparatively large quantity of detritu3 from the tissues in 

the course of involution. From an open wound comes at first blood, and 
similarly in this case we have for the first few hours and days a bloody 
fluid, the lochia rubra vel cruenta. The microseopie examination of the 
secretion shows numerous red blood-corpuscles, portions of clots, and of 
decidual shreds. After a few days the secretion still stains the napkins 
a reddish-brown color, but the fragments have a pale yellowish appear- 
ance. The lochia after a week contain serum mixed with the coloring 
matter of the blood, together with scattered flat epithelial and cylindrical 
cells, and are called lochia serosa. As the external wounds gradually take 
on granulations, leucocytes are mixed with the secretion. These cells 
are at first few in number, but increase until after the end of the second 
week; the secretion is purulent, the lochia alba vel purulenta. These 
changes take place gradually; approximately it may be said that the 
lochia rubra appear for three days; the lochia serosa from the third to the 
eighth day contain much albumin, mucin, fat, chlorides, and phosphates, 
their reaction being alkaline. In the second week the lochia alba appear, 
containing leucocytes, fat, cholesterin, and a few connective-tissue cells. 
The normal acid secretions of the vagina finally give to the lochia an 
acid reaction. The flow from the uterus itself should always be sterile, 
and for the first day or two the lochia normally contain no micro-organ- 
isms. It is not, however, unusual for their presence to be demonstrable 
in the secretion later, and provided that they come only from the vagina 
their occurrence must not be considered abnormal. 

The amount of the lochia has been variously estimated by different 
authors. Gassner, quoted by Winckel, gives the following figures: 

Lochia cruenta 1000 grammes. 

Lochia serosa 260 " 

Lochia alba 205 

The amount necessarily varies in different cases. Where there is faulty 
involution the lochia are more profuse. In nursing women the duration 
of the flow is generally shorter than in the cases in which the women do 
not suckle their children. The discharge diminishes gradually, and 
usually disappears entirely between the second and the sixth week. 

After-pains. The changes going on in the inner genitalia are brought 
about principally by contractions of the uterus, occurring at more or less 
regular intervals, and which are sometimes appreciated by the patient, 
since they produce what are called " after-pain s." It is to be noted 
that primiparse seldom complain much of these pains, so that when they 
are at all marked some pathological process is generally to be suspected. 
In multipara? they occur quite frequently, but" can usually be easily con- 
trolled. The intensity of the after-pains is in inverse proportion to the 
strength of the uterine contractions during parturition, so that, as a rule, 
patients who have had a speedy, almost painless, labor, are apt to suffer 
more during the puerperium. 



THE PUERPERAL STATE. 253 

Urine. Notwithstanding the great activity of the skin after labor the 
amount of urine excreted by the kidneys should be rather more abundant 
in quantity than under ordinary circumstances. The woman may, how- 
ever, pass but little urine at first, and after the first five or six hours the 
bladder may become much distended. Three factors contribute to bring 
about this accumulation: (1) The amount of urine passing into the blad- 
der from the kidneys is greater than usual. (2) The expulsion of the 
contents of the uterus, the child, placenta, and liquor amnii, has removed 
quite a large mass from the maternal body, as a consequence of which 
the intra-abdominal pressure is decreased and the abdominal walls are 
flaccid, the bladder being thus allowed more room to expand and less 
resistance being exerted to its distention. (3) The woman, finding, per- 
haps, that a few drops of the urine trickling down over small lacerations 
of the outer genitalia cause a disagreeable smarting sensation, may thus 
be led almost unconsciously to retain her urine as long as possible. 

The increase in amount seems to be mainly in the water, the urine 
being of rather a lower specific gravity than usual. The total amount 
of urea excreted is practically unchanged, the increase, if any, being quite 
insignificant. Sodium chloride is present in relatively larger amounts; 
phosphoric and sulphuric acids are both somewhat increased. Peptone 
is usually found in the urine. Its presence bears probably some relation 
to the involution of the uterus, since it is found from the second half of 
the first day after labor to the seventh day. Winckel reports a case of 
Porro's operation in which it was absent. Acetone is said to be a con- 
stant constitutent of the urine of puerperal women. Albumin may be 
found in some cases, due to a temporary renal hyperemia, but its presence 
must be considered abnormal, and its persistence is always of grave 
import. The presence of sugar in the urine for a few days is not neces- 
sarily a serious symptom, and is commonly to be explained by reabsorp- 
tion of milk-sugar from the mammary secretion. Its occurrence is not 
rare and is more especially frequent in cases in which there is distention 
of the breasts either from over-secretion or from failure on the part of 
the child to utilize the proper amount of milk. 

Bowels. The bowels are apt to be sluggish at first, and do not move 
naturally for several days. This may be accounted for principally by the 
lessened intra-abdominal pressure. The fact that the woman receives only 
a liquid diet, and that the watery parts are given off in a great measure 
through the skin, and in the milk, urine, and lochia, leaves little solid fecal 
matter to be evacuated, especially if the bowels have been well cleared 
out before labor. That lessened peristalsis does not play much part in 
causing the constipation is proved by the fact that the excreta are passed 
along the bowels, the rectum being in many cases enormously distended. 

Temperature. In view of the extensive changes which are going on in 
the body and the great amount of material to be absorbed and eliminated, 
it certainly would at first sight appear extraordinary that the process is 
not accompanied by grave pathological symptoms. Under ordinary cir- 
cumstances it might be expected that the absorption of a pound or more 
of tissue which undergoes retrogressive metabolism would certainly give 
rise to a high temperature. Careful observations, however, based upon 
long experience have proved beyond doubt, that normally the puerperium 
passes without fever. In the past it was an established belief that the 



254 PHYSIOLOGY OF THE PUEBPEBIUM. 

paerpera daring the first few days, especially when the secretion of milk 

began, must have fever. This idea was rendered more plausible by the 

fact that not a few women, especially primipar.c, undergo no little emo- 
tional excitement. The pain which accompanies the secretion of milk, 

some difficulty in coaxing the child to nurse, the soreness experienced 

when it seizes the nipples, all tend to exeite and worry the mother, espe- 
cially if she be a primipara. The physician or nurse finds the pulse 
quickened, the face red, and the patient complaining of exhaustion, and, 
possibly, of severe headache. Surely under these circumstances it was 
not unreasonable to say that fever was present. The clinical thermom- 
eter, however, has upset entirely this opinion. 

There is No Such Thing as Milk Fever. The secretion of milk of itself, 
be the breast ever so hard or swollen, goes on in innumerable cases with- 
out a rise of temperature. Careful observation has also proved that 
retention of milk does not cause fever. Elevations of temperature may 
be caused by trifling circumstances, but if the rise is not very slight and 
quite transient we are in face of some pathological factor. Zweifel holds 
that a temperature of 37.6° C. or 37.7° C, 99.5°-100° F., in the axilla 
is always pathological. If the puerpera has not been subjected to harmful 
influences she will have no fever. Milk fever is traumatic fever, and trau- 
matic fever means infection. 

It is hardly possible to repeat this fact too often, for if it is neglected 
valuable time may be wasted in vain hopes, when a rigid search might 
reveal the pathological cause and enable us at once to institute measures 
to rectify the conditon. 

The Pulse. After completion of the third stage the pulse usually decreases 
very markedly in rapidity. The first sound of the heart often takes on 
a soft murmurish tone. This change may not occur at once, but usually 
takes place within the first twelve hours, the rate falling to 60 or less, 
and in exceptional instances to 40 per minute. A pulse as low as 34 has 
been recorded. The arterial tension is not increased. The duration of 
this slowing of the heart varies in individual cases, being usually in 
direct proportion to the lowness of the rate. No completely satisfactory 
explanation of this phenomenon has been arrived at. Doubtless the 
complete physical and mental rest, coming as it does after a period of 
anxiety and suffering, plays an important part, although it does not by 
any means of itself afford a sufficient explanation. Olshausen thought 
that the absorption of fat and the presence of fat emboli could account 
for the slowing of the pulse. It is possible that the stasis occurring in the 
abdominal veins may account in part for the slowing of the circulation, 
or that the shutting off of a great mass of blood going to the uterus, by 
relieving the heart of some of its work, may act in the same way. Both 
these theories, however, are rendered somewhat unsatisfactory from the 
fact that the slowing of the pulse also occurs after early abortions, in 
which the shutting off of the utero-placental circulation or stasis in the 
abdominal veins could hardly figure as relieving the heart of much extra 
work. The same objection applies to the attempt to find an explanation 
in the increase of the pulmonary capacity as a consequence of the expul- 
sion of a large abdominal tumor. It is only natural that the rate and 
character of the pulse of the puerpera may be temporarily influenced by 
very trifling causes. 



THE PUERPERAL STATE. 255 

The Respiration. At one time it was held that the pulmonary capacity 
was increased after labor. Modern investigations, however, do not bear 
out this assumption. Out of 50 cases examined by Yagas the pulmonary 
capacity was found to be the same as before labor in 26 cases. It was 
increased in 17 and decreased in 7 cases. The character of the respira- 
tions is not markedly altered. 

The Skin. Formerly the " puerperal sweats " were well known. They 
were noted especially during sleep and often attended by what was 
thought to be a characteristic odor, which was probably dependent upon 
the presence of fatty acids, and often accompanies severe sweating. The 
older obstetricians welcomed their appearance and regarded their absence 
as a somewhat ominous sign. At the present day, now that the close, 
overheated lying-in chamber has given place to the cool, well-ventilated 
room, one rarely sees drops of sweat upon the forehead of the puerperal 
woman. 

The skin of the abdomen shows shining whitish or reddish lines, which 
at a later date become quite white, the linese albicantes. These are usually 
arranged in the form of crescents running from the groin toward the 
umbilicus, and are far more numerous and more deeply marked below the 
navel than above it. They are caused by overstretching of the skin 
during pregnancy and the subsequent replacement of part of the corium 
by scar tissue. Areas of pigmentation which have appeared on the face, 
abdomen, around the nipples, and elsewhere on the body during preg- 
nancy, gradually begin to fade during the puerperium, although, as a 
rule, they do not entirely disappear. The areolae of pigmentation around 
the nipples, more marked in brunettes, grow less conspicuous, but are 
never entirely obliterated. 

The Digestive Apparatus. Just as the excretions of one organ serve to 
nourish other organs, it is not improbable that a considerable amount of 
the products of the involution going on in the genitalia is utilized as food 
for the other tissues of the body; but that all are not so used is proved 
by the fact that peptone can be demonstrated in the urine. The power 
of the digestion of solid food is for a time enfeebled. Thirst is usually 
present, and is easily accounted for by the great drain of water from the 
body in the increased perspiration, the lochia, the milk, and the urinary 
secretion. The sluggishness of the bowels has already been referred to. 

Loss in Weight. As elimination exceeds ingestion, it is self-evident 
that the puerperal woman must lose considerably in weight. The amount 
lost has been variously estimated as from one-twelfth to one-eighth of 
the entire body-weight in the first seven days. Non-nursing women and 
primiparse lose less than nursing mothers and multipara, the loss being 
actually, though not relatively, greater in proportion to the normal body 
weight. Under ordinary circumstances the diminution should cease at 
the latest by the ninth day. 

Lactation. The breasts for a short time after labor afford a secretion 
similar to that which they contained during pregnancy. This early milk, 
or, as it is called, " colostrum/ ' is a whitish or faint yellowish, viscid 
fluid resembling milk, but differs from it chemically in being richer in 
sugar, fat, and salts. It seems to have a laxative effect upon the child, 
and sweeps away the meconium from the bowels. This action has been 
attributed to the separate or collective effect of the excess of the several 



256 PHYSIOLOGY OF THE PUERPEBIUM. 

ingredients. One author advances the view that it acts by its indig 
bifitv. Mioroeoopically it differs from milk in containing the so-called 
u ooloetrnm " cell, which is nothing more nor Less than a large epithelial 
cell studded with fat globules. The fat globules of the colostrum arc 
not as uniform in size as those of milk. 

The true milk secretion begins ahout the second day or occasionally on 
the third day. The breasts, which have already enlarged during preg- 
nancy, become still more tense and swell to such a degree that they are 
often very sensitive, and may be the seat of considerable pain. The pain 
and emotional disturbance, especially if there is trouble in making the 
infant take the breast, may give rise to a slight elevation of temperature. 
The so-called milk fever, a myth of the prebacterial stage of medical 
knowledge, has been discussed. Microscopically, human milk is seen to 
consist of minute oil globules of rather uniform size, floating in a trans- 
parent, colorless plasma. Human milk, like that of all other animals, 
is an emulsion. The emulsifying agent is an albuminoid, the casein. 
The plasma contains milk-sugar and inorganic salts. The fats, sugar, 
and casein are produced from the cells of the acini of the glands. The 
liquid portion, the plasma, is obtained from the blood. As regards its 
chemical constitution, milk varies in different women or at different times, 
and even in the two breasts of the same woman. The approximate chem- 
ical composition of rich human milk is shown in the following table : 

Water 88.9 per cent. 

Solids 11.1 

Casein 3.82 " 

Fat . 2.66 " 

Milk-sugar . 4.36 

Inorganic salts 0.14 

The quantity of milk secreted varies also in different women and at 
different times. During the first three days the whole amount may be 
between 50 and 200 cc, but the quantity rises rapidly, until by the 
ninth day 400 to 450 cc. are being secreted daily. The character of 
the milk is altered by various conditions of the mother. Certain medi- 
cines when given the mother are given off almost unchanged in the milk 
secretion, and may seriously disagree with the nursing child. It has 
been found also that mental or physical disturbance in the mother may 
so alter her milk so as to render it unwholesome. The reappearance 
of the menstrual function makes a change in the character of the milk. 
The disturbance, however, is usually temporary, and subsides immediately 
after the menstrual period. 

In women who do not suckle their children milk secretion goes on for 
a couple of days; during this time the colostrum corpuscles gradually 
decrease, but again show a relative increase. The breast undergoes a 
physiological atrophy; the secretion gradually becomes less, until at the 
end of from fourteen to sixteen days it practically ceases. 

The period of lactation may be said to last for almost one year, though 
at the end of the sixth or eighth month the quantity and quality of the 
milk secreted often begin to fall off. Some women nurse their children 
far into the second year, but the nutritive properties of the milk are of 
necessity very poor. 



THE PUERPERAL STATE. 257 

Care of the Puerperal Woman. 

Remembering that the puerperium after a properly conducted labor is 
a natural condition, it remains for the obstetrician, while abstaining stren- 
uously from meddlesome interference with nature, to take such precau- 
tions as shall prevent the physiological from merging into the pathological 
upon which it so nearly borders in these cases. The main treatment may 
conveniently be discussed under three heads : (1) proper nutrition; (2) 
absolute rest of body and mind; (3) proper hygiene with aseptic treat- 
ment of the wounded parts. 

Nourishment. Liquids should be given for the first two or three days. 
Milk is the best food, but an occasional cup of beef-tea, clear soup, or 
weak cocoa is often very grateful to the patient. For thirst, water must 
be principally given, but a cup of tea, if the patient expresses a desire 
for it, will do no harm. After the third day a gradual return to the 
usual diet may be made. After the first week extra nourishment, prefer- 
ably in the shape of milk between meals, should be allowed. Malt liquors 
or wines are usually unnecessary; if, however, the woman is habituated 
to a moderate use of them they may be allowed in very small quantities. 
The patient's own tastes may be consulted and will usually serve as a 
guide for the diet to be given, provided nothing too heavy or manifestly 
indigestible be desired. If the patient is fond of eggs they form a very 
nourishing food, and can be given to her prepared in a number of different 
appetizing forms. 

Rest. The puerpera should have complete bodily and, what is just as 
important, absolute mental rest. After remaining quiet for a few minutes 
after the completion of the third stage of labor, the mother usually desires 
to see her child. This wish may generally be gratified; but as soon as pos- 
sible after the linen has been changed and she has been made comfortable 
the room should be moderately darkened and the patient should be left 
to sleep. After she awakes the infant may be put to the breast for a few 
minutes. For the first two or three days the woman should be kept flat 
on her back, with the head only a little raised on a small pillow. When 
nursing the infant she may assume the lateral position, if this is found to 
be more convenient, but all sudden changes of position, especially the 
sudden arising into a sitting or standing posture, for the first few days 
must be strenuously avoided. Neglect of such precautions has not 
infrequently been followed by fatal syncope. After the uterus has had 
time to contract firmly and the sinuses have been permanently closed, 
the danger becomes minimized; but it is, nevertheless, advisable to avoid 
any sudden change of posture for some time. It is well to secure 
greater safety, even at the expense of a little discomfort, and for the 
first few days not to allow her to rise even to pass urine or to have a 
movement from the bowels; for this purpose she should be induced to 
use the bed-pan. It is not uncommon for patients to experience con- 
siderable difficulty in passing the urine while in the recumbent position; 
this, however, may generally be obviated by applying a warm wet aseptic 
compress to the vulva. Occasionally the sound of a little water trickling 
into the bed-pan will have a salutary effect. If no urine has been passed 
for over eight hours, and the various simple expedients have failed to 
cause the patient to urinate voluntarily, she will have to be catheterized. 

17 



258 PHYSIOLOGY OF THE PUEBPEBIUM. 

Glass catheters are obeap, and if broken can readily be replaced. They 

arc better than those of other material, since they can easily and certainly 
be kept aseptic. Before and after use they should he thoroughly cleansed 
with hot water, and in the intervals may he kept in 1 : 40 carbolic-arid 

solution. Before being w^'^l the catheter is rinsed thoroughly in sterilized 
water in order to free it from the carbolic acid. Catheterization demands 
complete exposure of the parts, and as thorough asepsis as possible. 
Without the former the latter is impossible, and catheterization under 
the bedclothes is inadmissible. A little tact will generally suffice to 
overcome the objections of any patient who has been accustomed to the 
old method and who may feel a little sensitive about the procedure. The 
external genitals, more particularly the parts immediately around the 
meatus, should be cleansed from lochia and the labia be held apart while 
the catheter is being introduced. These precautions are necessary every 
time catheterization is employed if we wish to provide against the chances 
of setting up what may probably be a serious cystitis. When it has been 
found necessary to draw off the urine the catheter should be used once, 
and as soon as the bladder begins again to be moderately distended the 
patient should be urged to make several efforts at emptying the bladder 
spontaneously. If she is unsuccessful in her attempts she should not 
be allowed to go more than eight hours without having her bladder 
emptied. In a few cases repeated catheterization will be forced upon us, 
but we should not fail to do our utmost to obviate the necessity as soon 
as possible. 

The bowels should be opened by the third day. This is best accom- 
plished, if it does not occur spontaneously, by some simple enema, pref- 
erably of soap and water. Should this prove ineffectual, and large 
masses of feces be present in the rectum, three or four ounces of sweet 
oil may be injected carefully and allowed to remain for half an hour, 
after which another simple enema may be given. A dose of castor oil, 
given in capsules if preferred, will generally aid very much in bringing 
about a satisfactory result. Care should be exercised in giving medicines 
to the nursing woman, since many drugs, notably the minerals and rhu- 
barb, are excreted partially in the milk secretion, and may thus disturb 
the digestion of the child. Salts are not recommended in these cases, 
because they are supposed to diminish the secretion of milk; in many 
instances, however, especially when there is abundance of milk, they seem 
to act well. 

Perfect mental rest is of the greatest importance to the puerperal 
woman. A short nap will do more to strengthen and invigorate her than 
any amount of congratulations on the part of relatives and friends. With 
the exception of the husband or mother, who may be allowed to remain 
if their presence seems to quiet and comfort the patient and does not 
interfere with her rest and sleep, all other visitors should be rigorously 
excluded. The child should not be kept near enough to disturb her 
by its cries, and should under no circumstance be allowed to sleep in 
the same bed with its mother. If this rule were always carried out the 
rate of mortality from " overlying " would be considerably diminished. 
Until she has regained her strength the patient should be kept free from 
all household cares. These should be delegated to the nurse or some 
other competent person. The anxieties and troubles of others should not 



THE PUERPERAL STATE. 259 

be brought to her for sympathy. Excessive joy or grief has not infre- 
quently caused death in puerperal women. Mental emotion has been 
known to bring about inhibition of the contractions of the uterus, and 
thus to cause dangerous flooding, and even if it does not produce serious 
symptoms, excitement always interferes with the proper progress of 
convalescence. 

The Lying-in Room, whenever it is possible, should be in some quiet 
part of the house as far removed as possible from the noise of the house- 
hold and street. It should be well lighted and airy, but should be so 
arranged that it can be shaded when necessary, since a partially darkened 
room is more productive of rest and sleep. The light should never strike 
directly into the patient's eyes, and there should be no perceptible draughts. 
Ventilation should be so arranged that no one on entering should be able 
to detect any odor. The temperature should be kept steadily between 
60° and 70° F. No noise or disturbance should be permitted, kt no 
time must the lying-in room be made a general meeting place for a large 
circle of relatives and friends. The woman's linen and the bed should 
be kept scrupulously clean. Frequent changes of the napkins and bed 
linen should be made. This can be done readily, without disturbing the 
patient, by making use of draw sheets. 

After-pains. In primiparae, as has been said, the after-pains are rarely 
severe enough to demand interference. In multipara?, on the other hand, 
they may be very annoying and may seriously discommode the patient, 
interfering with sleep and rendering her miserable. Under such circum- 
stances some treatment must be instituted. The physician should never 
consider any discomfort of his patient as too trivial for his serious atten- 
tion, and although at times he may not think it wise to have recourse to 
drugs for her relief, he will not hesitate to employ them whenever the 
situation demands it. Opium or its alkaloid, morphine, relieves pains 
more effectually than any other drug in the Pharmacopoeia, but is not 
always well tolerated. Chloral alone, even in comparatively large doses 
of 15 or 30 grains, is not very efficacious in relieving pain, although its 
effect is quieting. Some such combination as the following generally 
acts very well : 

Morphinse sulphatis gr. %-% 

Chloral hydrate gr. 10-20 

Bromides are practically worthless against acute pain. They act slowly 
and very feebly. Antipyrine, antifebrine or acetanilid, and phenacetin 
have considerable analgesic action and are occasionally of service. Their 
use should, however, in no case be prolonged, as they are all depressants 
and are said to interfere with involution. Should opium be given it is 
necessary to keep its constipating action in mind and be governed accord- 
ingly. 

Care of the Genitalia. If the labor has been normal and no instruments 
have been used, and no incautious or too frequent vaginal examinations 
have been made, it is safe to assume that the condition of the genitalia 
is physiological, and consequently demands only rigid asepsis to keep it so. 
No vaginal douches are necessary after the completion of the third stage. 
The vulva should be washed off with a stream of sterilized water, its 
action being aided by gentle friction with sterilized fingers or pledgets of 
sterilized cotton held in the forceps, and should then be protected by a 



2b'0 PHY8I0L0GY OF Till: ITERPERll M. 

generous dressing of sterilized ootton or gauze. The dressings should 
be changed every hour or two for the first >i\ or eight hours, and during 

the next day every three hours. After this they should be changed three 
or more times daily, according to the amount of soiling. When the dress- 
ings are removed the external genitals should be cleansed of lochia, and 
Bhould then be washed with an antiseptic solution, which in turn should 
be removed with sterilized water. For this purpose under ordinary cir- 
cumstances a saturated solution of boric acid acts best. A 1 to 2000 or 
3000 solution of bichloride might be used, provided one could be sure 
that none of it was allowed to enter the vagina. In view of the fact that 
considerable danger of mercurial poisoning exists, it is better to make use 
of some less toxic antiseptic. A 2 per cent, or a 1 per cent, solution of 
creolin may be employed, but the odor may render its use disagreeable 
to the patient. Should the discharge become fetid, antiseptic douches 
may be called for. Bichloride of mercury and carbolic acid are dangerous 
in the condition in which the vagina and uterus are at this time, but may 
be employed with caution in weak solutions and when carefully controlled 
by the physician. A 1 per cent; solution of lysol, a 2 per cent, solution 
of creolin, hydrogen peroxide in full strength, diluted chlorine water, and 
permanganate of potash in weak solutions have their advocates. Should 
the woman show evidences of infection the case ceases to be physiological 
and becomes pathological. The proper course to be pursued under such 
circumstances will be found in the section on the Pathology of the Puer- 
perium. 

Nursing the Child. Four or six hours after labor, after the mother has 
been refreshed by a good sleep, the child may be put to the breast for a 
few minutes, and then for two or three days, until the secretion of milk 
is established, at intervals of four hours, after which it should be nursed 
every two hours from 6 a.m. to 10 p.m. In this way the child receives 
nourishment nine times in the twenty-four hours, and the mother can 
obtain seven hours or more of uninterrupted sleep. Occasionally one 
nursing at night is necessary. Without regularity in nursing it is hardly 
possible for either mother or child to do well, and many cases of severe 
debility and anaemia in nursing women are due mainly to over-frequency 
in nursing, while the stomach of the child, from want of rest and im- 
proper quality of the milk, is also seriously disturbed. The nipples should 
be gently cleansed after and before each nursing with a saturated solution 
of boric acid, and should then be dried by patting with some soft absorb- 
ent material. No rubbing should be employed. Should the nipples tend 
to become sore or cracked, inunction with a little cacao-butter, after each 
nursing and cleansing, may do valuable service by protecting them from 
the air and by softening and rendering the skin more pliable. The mother 
may, perhaps, be unwilling to suckle the child, but when no contraindi- 
cation exists she should be persuaded to do so for her own sake and for 
the child's welfare. The act of suckling promotes involution in the geni- 
talia through reflex nervous action, and thus the mother is benefited. For 
the infant no food is so suitable as its mother's milk, and thus the child 
is benefited. There are, however, certain conditions in which nursing 
the infant may be impossible or inadvisable. In cases in which the 
mother's health is very feeble lactation might be too serious a drain upon 
her. Under such circumstances it will be better for the infant, too, to pro- 



THE PUERPERAL STATE. 261 

hibit suckling, as the mother's milk will almost certainly be defective in 
quality or quantity, and probably in both. A tuberculous mother, even 
when comparatively strong, should not suckle her child, for fear that she 
might infect the infant. This same rule applies also to cases in which 
the woman has contracted syphilis late in pregnancy, since it is just pos- 
sible that the child may not be syphilitic. If, however, the disease was 
inoculated previous to or at the time of conception the child should be 
suckled by its mother, unless other contraindications exist. It is not 
right to subject a non-syphilitic wet-nurse to the risk of infection by 
allowing her to suckle the infant of a syphilitic mother, even should all 
signs of syphilis in the child be lacking. The condition of the breasts 
may contraindicate nursing the child; inversion of the nipples, cracked 
nipples, mastitis, or defective secretion may render suckling impossible 
or inadvisable. Defect in the quality or quantity of the breast-milk will 
quickly make itself apparent by the fact that the child does not thrive 
or gain in weight as it should, even if it shows no signs of serious diges- 
tive disturbance. Moderate "over-feeding" of the mother, combined 
with general tonic and supporting treatment and proper hygienic measures, 
will often rectify this faulty condition. It is. of course, necessary to see 
that the over-feeding does not go far enough to in j are the woman's diges- 
tion. The exhibition of drugs, of which there is so long a list under the 
heading of galactagogues, rarely, if ever, does any good. In many cases 
the use of them undoubtedly does harm. Strychnine, iron, and quinine 
in tonic doses are frequently beneficial. It is well to order a certain 
amount of milk at intervals during the day; if taken between meals it 
often agrees better. Malt liquors or extract of malt in moderate doses suits 
some patients. Somatose is believed to be useful. Thyroid extract, gr. j, 
three to five times daily, is said to improve the quantity and the quality 
of the milk. Inversion or retraction of the nipples should, as far as pos- 
sible, have been rectified during the later months of pregnancy. Cracked 
or fissured nipples should be kept scrupulously clean, washed frequently 
with a saturated solution of boric acid, and anointed with cacao-butter 
over which a protective film of the compound tincture of benzoin may 
be applied. A well-fitting nipple-shield is often a great comfort when 
the act of suckling irritates the nipples. In the more severe cases the 
breasts may be drawn by means of a breast-pump and the milk given to 
the child with a spoon or medicine-dropper. Mastitis or mammary abscess 
generally renders the milk unfit food for the infant. Should the breasts 
become painful from over-distention, or should their increased weight 
produce irritation or disagreeable sensations, a compressing or supporting 
bandage may be applied. A wide roller-bandage properly applied will 
answer the purpose as well as a specially made breast-binder when the 
latter cannot be procured. Saline cathartics and moderation in the use of 
liquids will aid in diminishing over-distention from profuse secretion. 
Where the child is puny and does not draw enough milk to relieve the 
gland, the breast-pump may be made use of. 

When for any reason it is proper that lactation be brought to an end 
during the puerperium, the application of a proper bandage to the breasts 
and moderation in the use of liquids generally answer every purpose. 
The woman will probably experience some pain in the breasts for several 
days, but this under ordinary circumstances soon subsides and the glands 



262 PHYSIOLOGY OF THE PUEBPEBIUM. 

Undergo involution. Occasionally it may be necessary to give saline 
Cathartics. Atropine and iodide of potassium are Strongly recommended 
by various author.-. Of the latter 5 to lo grains may be given in water, 

carbonated water, or milk three times a day. Ilirt prefers to give this 
drug in hot milk. The syrup of sarsaparilla, in which it is bo frequently 

given, adds iu no way to its efficacy, and the combination makes a nause- 
ous mixture, which, strange to say, however, is not disagreeable to many 

patient-. 

The Visits of the Physician. The physician after the completion of 
labor should always remain within call until the uterus has firmly con- 
tracted and all immediate danger of hemorrhage has passed. He should 
see that the patient is as comfortable as possible, and so order arrange- 
ments that she will get the necessary quiet and refreshing sleep. The 
child's condition should have been examined into, and any defects in 
formation should have been noted. The umbilical cord should be 
inspected to make sure that it is in order and that the ligature has not 
slipped. Just before leaving the physician should give clear and distinct 
orders to the nurse in charge concerning the management of the woman 
and child. These may be put in writing if thought advisable. A visit 
should be made within twelve hours after labor, and at that time both 
mother and child should be examined carefully to see that all is going 
well. The physician himself should note the temperature, pulse, and 
respiration, keeping in mind the ease with which injurious distention of 
the bladder can occur and the fact that the passing of urine is often 
reported with a too full bladder and may simply mean an overflow (enu- 
resis paradoxa). The state of the skin, the digestive apparatus, the 
amount and character of the food, the condition of the uterus and the 
lochia, must all be inquired into. The woman must not be allowed to 
become constipated. After the third day she should have a daily bowel 
passage. The condition and welfare of the child must not be forgotten. 
Inquiries must be made as to whether it has been fed or suckled, whether 
it is thriving and gaining weight or not, and about the conditions of its 
various functions. The nurse should be directed to keep for the reference 
of the physician a record of temperature, pulse, and respiration, of the 
bowel passages of both mother and child, and of the number of feedings 
of the child. Anything else which she may deem of importance for the 
treatment of the case should be duly reported. Temperature, pulse, and 
respiration should be taken three times a day for the first week; after 
that tw r ice a day suffices. For the first week the physician should make 
a daily visit, after which time, providing the nurse be competent to care 
for the case properly, it will be sufficient to see the patient every second 
or third day. The patient should not be allowed to get up until the 
change is sanctioned by express order of the physician, and she must 
continue under his observation until convalescence is fully established. 

Tardy Involution. When the progress of involution is abnormally slow 
it may be promoted by the use of friction, faradism, or small doses of 
ergot. Hot vaginal douching is useful, but this is a matter which can 
seldom be trusted to the nurse. 

Friction is applied to the uterus by the nurse in the same manner as 
in the third stage of labor. The hand, laid flat on the abdomen, moves 
the abdominal wall with it in a circular direction over the anterior surface 



THE PUERPERAL STATE. 263 

of the uterus. The treatment is continued for ten or fifteen minutes 
twice daily. 

Faradism may be applied through the uterus from side to side, the 
electrodes resting on the abdomen, or one on the abdomen over the uterus, 
and the other over the upper sacral region. The current need not be 
strong enough to cause pain. 

Ergot in doses of ten or twenty minims three times daily is frequently 
of service. 

A hot vaginal injection at a temperature of 48.8° C, 120° F. and re- 
peated twice daily is effective. Douches, however, should, as a rule, be 
administered only by the physician and with extreme aseptic precautions. 

A frequent cause of tardy involution, and which may pass unsuspected, 
is a mild infection of the endometrium. In such cases curetting is 
generally required. Curetting on this indication alone is seldom ad- 
visable earlier than the third or fourth week of the puerperium. 

Displacement of the Uterus. The uterus sometimes becomes retroverted 
or retroflexed in the latter part of the puerperal month. This is most 
frequently the case in subinvolution, and particularly when retrodisplace- 
ment had existed before pregnancy. Evidence of the malposition will 
usually be afforded by pelvic tenesmus, by pain in the sacral region, and 
by return of the bloody flow. These symptoms are most marked on 
getting up. If on vaginal examination the diagnosis is confirmed, the 
uterus should immediately be replaced manually and supported by a suit- 
able hard -rubber pessary. The pessary must be worn for two or three 
months. By the timely adoption of this treatment a permanent retro- 
version may almost invariably be prevented. 

Pelvic Examination. It should be a routine practice to make a bimanual 
examination of the pelvic organs in the third or fourth week of the puer- 
perium. The object is to determine the presence or absence of injuries of 
the vagina or cervix, the degree of uterine involution, and the possible 
existence of retrodisplacement of the uterus or other abnormal conditions. 

The Diagnosis of the Puerperal State. 

It is sometimes important for medico-legal or other reasons to deter- 
mine whether or not a woman has been recently pregnant, or whether an 
abortion or labor at full term has lately taken place. In such cases the 
patient herself may be dead or, if living, may for various reasons deny 
absolutely the imputation of pregnancy, so that it will be left to the physi- 
cian to determine from objective signs the true condition of affairs. Since 
the decision may involve serious consequences to one person or more, it 
is especially important not only that the report of the physician should 
be accurate, but that he may be able to bring forward proof which in the 
eyes of skilled witnesses may be considered irrefutable. 

The evidences of a recent delivery may be divided into three classes : 
(1) positive, (2) probable, and (3) uncertain. 

The Positive Signs of the puerperal state are derived from the ovum, 
and are only to be recognized by means of the microscope. The demon- 
stration of placental tissue, especially chorionic villi, in a scraping or in 
a section taken from the uterus, is proof positive that the woman has 
been pregnant within a reasonably recent period. 



264 PHYSIOLOGY OF THE PUEBPEBIUM. 

The Probable Signs arc numerous. The finding under the miorosoope 

of the so-called decidual cells, the much-enlarged cells of the uterine 

mucosa or deoidua, is nol absolutely conclusive, since very similar cells 

are found in certain cases of endometritis. Nevertheless the occurrence 

of these large cells, when found in conjunction with other probable signs, 
affords strongly presumptive evidence of a pregnancy. The same may 
be -aid of the abdominal Btrise or Liuea albicantes, the contused condition 

of the genitalia, the presence of secretions resembling the lochia, the 
dilated smooth vagina, the soft and lacerated cervix, die enlarged uterus, 
and the .swollen breasts with their well-marked areola? and their secretion 
of colostrum or milk. These signs taken singly are not positive, since 
the occurrence of any one alone, or of several of them together, may be 
clue to conditions other than pregnancy. The enlarged uterus, the soft- 
ened and more or less lacerated cervix, the abdominal stria?, and at times 
even the milk-secreting breasts may all have had their origin in the pre- 
vious presence and delivery of a large submucous uterine fibroid. It is 
only when a number of them are present at one and the same time that 
the proof of a preceding pregnancy may be said to be established beyond 
reasonable doubt. 

The Uncertain Signs include the relaxed wrinkled condition of the 
abdominal walls, venous varices of the lower extremities, profuse sweats, 
and other less important symptoms. Such conditions are, of course, met 
with also in men as well as in women who are not pregnant. The 
relaxed, withered appearance of the abdominal walls may be due to the 
absorption or rapid disappearance of a large amount of fluid from a pre- 
vious ascites or a large ovarian cyst. Mottled areas resembling the true 
stria? albicantes occur in people who have previously been stout and have 
subsequently lost flesh, and are due, as in the puerperal state, to the 
removal of the distention. Signs of this class, therefore, can only be 
regarded as affording confirmatory evidence of a condition indicated by 
those of the other categories. As regards the time that has elapsed since 
delivery, the condition of the lochia, of the vaginal wounds and the 
breast function must be taken into consideration. It must be remem- 
bered that placental and chorionic villi may be found in the uterus 
months after delivery has taken place. Our decision, therefore, on this 
point can never be more than approximate. 



CHAPTER XI 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



Fig. 209. 



Anatomy and Physiology. 

Before considering the management of the new-born infant, it may 
be well to recall some of the more important points in the anatomy of 
early infancy. 

It may be stated in general that the thoracic and abdominal viscera of 
the infant are relatively more highly developed than the brain and gen- 
erative apparatus. The bones are soft and flexible, from the excess of 
animal matter and deficiency of calcium phosphate. The muscular struc- 
tures are poorly developed, while the circulatory and lymphatic systems 
are relatively large. 

The Cranium. The cranial vault at birth is more or less plastic, owing 
to the fact that its bones are not fully ossified nor firmly united. The 
base of the skull is more unyielding than the frontal and parietal por- 
tions. The posterior fontanelle is usually nearly closed at birth, while 
the anterior generally remains widely open. (Fig. 209.) The closure 
of the anterior fontanelle at birth, or soon 
after, is abnormal, and may indicate that the 
brain is abnormally small. When it is ab- 
normally large it indicates a lack of develop- 
ment of the bones. 

As the jaw is rudimentary, and the teeth 
absent, the facial part of the skull is rela- 
tively small. 

The Spinal Column is straight at birth, but 
marked by great flexibility. The usual adult 
curvatures in the dorsal and sacro-coccygeal 
regions are but little developed in early in- 
fancy. The development and co-ordinating 
powers of the spinal muscles are feeble. It 
is usually several weeks before the infant can 
hold its head erect. 

The Nervous System is imperfectly devel- 
oped at birth. Although the brain is large, it is soft and presents no 
sharp distinction between the gray and white matter. The spinal cord 
is relatively in a higher stage of growth than the brain, especially the 
anterior horns. The posterior and sensory portions of the cord are more 
immature. This explains the fact that motor manifestations are so active 
at this time, as sensory irritations and disturbances are quickly reflected 
into the predominant motor area. The rapid and irregular character of 
the muscular movements is evidence of this physiological fact. JSTo act 
of volition takes place in the new-born, all movements at this period 
being automatic or reflex. Keflexes can be obtained after birth not only 

( 265 ) 




Anterior and posterior fontanelles. 



266 PHYSIOLOGY OF THE PX7EBPEBIUM. 

from the cutaneous nerves of the surface, but from the nerves of special 
sense — the oprie, olfactory, and auditory. 

Special Senses. The pupils of the eye may be unequal in size, hut they 
react to light. The perception of light by the new-born is, however, 

imperfect, and the sense of sight, other than the ability to distinguish 

light from darkness, is not developed. Searing is also imperfect, as tin* 

cavity of the tympanum is apt to he filled with fluid and the tympanic 
membrane is placed in a horizontal position. The senses of taste and 
smell an* feebly developed at this time. The size of the peripheral nerves 
is relatively large, hut their function is not active during the first few 
days after hirth. 

The Thorax. The thorax is of small size in the new-born, the cir- 
cumference being a little less than that of the head. The cavity is shal- 
low in its antero-posterior diameter, the distance from the vertebral 
column to the manubrium being so small that compression may be 
induced by enlarged lymph-glands. There is a widening out, relatively 
great, toward the base of the cavity. The ribs are soft and elastic, 
being inserted in a rectangular and horizontal direction, which renders 
the respiration almost entirely abdominal. The intercostal muscles are 
thin and they exert little action on the ribs. The first dorsal vertebra is 
on a level with the upper margin of the sternum at birth, but later the 
second dorsal vertebra assumes this position. 

The Lungs. Just before birth the unaerated lungs lie in the posterior 
part of the thorax on either side of the pericardium. Immediately on 
delivery several deep and spasmodic inspirations should quickly inflate 
the lungs, which then assume a pinkish color. For the first few weeks 
the respirations are irregular in character, and they vary in frequency 
from 35 to 50 per minute. At times a pause of a few seconds between 
inspiration and expiration may be noted. The active growth and devel- 
opment of the infant results in the production of double the amount of 
carbon dioxide in proportion to its weight that is normal in later life. 
Hence the importance and stress of work that falls upon the lungs, which 
are smaller in proportion to the weight of the body than in the adult. 
The rapidity and tumultuous character of the respiration common in 
early infancy are thus explained. 

The Heart. The heart in the new-born is relatively wide, from the 
development of the right side, which has been functionally active during 
intra-uterine life. As a consequence, the apex-beat reaches to the mam- 
miliary line, and sometimes outside of it. A glance at the changes taking 
place in the circulation at birth will explain certain cardiac anomalies of 
early infancy. The blood from the placenta, after passing through the 
liver, with the exception of a small portion passing through the ductus 
venosus, joins with the blood returned from the lower extremities by the 
inferior vena cava. This is delivered into the right auricle, and passes 
through an opening, the foramen ovale, guided by the Eustachian valve, 
into the left auricle. It passes directly from the left auricle into the left 
ventricle, and thence into the aorta. The blood in the aorta is distributed 
principally to the head and arms, although a small portion may be car- 
ried by the descending aorta to the lower extremities. This explains the 
unequal development of the upper and lower extremities of the foetus. 
The return circulation from the head and upper extremities is collected 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



267 



by the superior vena cava, which empties into the right auricle, mixing 
with a little blood from the inferior vena cava. It passes over the 
Eustachian valve from the right auricle into the right ventricle, and 
thence into the pulmonary artery. Very little blood passes from the 
pulmonary artery to the lungs in the foetus, as these organs are solid and 
nearly impervious; the great mass of this blood passes through the canal 
of the ductus arteriosus into the descending aorta, where some is distrib- 
uted to the lower extremities and abdominal viscera, but most of it is 
carried to the placenta by means of the umbilical arteries. The rela- 
tively large development of the head and upper extremities at birth is 
explained by the fact that the fresh blood from the placenta passes first 
to these parts, as explained above, while the blood reaching the lower 
extremities by the descending aorta has already circulated through the 
upper part of the body. At birth, with the interruption of the placental 
circulation, the lungs should immediately inflate and draw off a large 
supply of blood through the pulmonary arteries. The foramen ovale 
gradually closes, and the opening should be completely occluded by the 
tenth day. At times this process is not complete, and a small valvular 
opening remains between the auricles. As soon as respiration begins, 
the ductus arteriosus commences to contract, and the occlusion should be 
complete from the fourth to the tenth day. The size of the heart in the 
new-born is large as compared with the rest of the body. According to 
Gray, this ratio is as 1 to 120 at birth, while in the adult the average 
is about 1 to 160. The arteries are also relatively wide in comparison 
with those of the adult, and the arterial pressure is small in young infants. 
The heart acts quickly and somewhat irregularly in the new-born, the 
pulse-rate varying from 125 to 140 or 150. 

The Blood. Upon ligation of the umbilical cord and the cessation of 
the placental circulation, important changes follow, not only in the 
infant's circulation but also in the blood itself. 

These changes appear to be first of a degenerative nature, and they are 
consequent upon a more perfect oxygenation of the blood. Immediately 
after birth the red corpuscles number six or seven millions per cubic 
centimetre, while by the fourth or fifth day the number has dropped to 
four or five millions. The size of the red corpuscles at birth is likewise 
variable, and the white corpuscles are present in much greater proportion 
than in the blood of the adult. The amount of blood in the new-born 
is less in proportion to the body-weight than in older subjects. The 
quantity of blood immediately after birth will vary somewhat according 
to the length of time during which connection with the placenta is main- 
tained. Just after birth, there is comparatively little fibrin in the blood, 
hence a certain slowness of coagulation. Cephalhsematomata are slow in 
solidifying, and meningeal apoplexies are apt to spread over the surface 
of the brain as a result of this condition of the blood. Its specific gravity 
is also somewhat lower than in later years. 

The Digestive Organs. A peculiarity of the mucous membrane of the 
mouth in the new-born consists in its thinness and the frequent exist- 
ence of minute patches of epithelium on the median line of the palate, 
the so-called ' ' epithelial pearls. ' ? 

The Stomach. The stomach is small, with more of a vertical than a 
horizontal inclination, the fundus being absent. It is little more than a 



268 PHYSIOLOGY OF THE PUEUPERIUM. 



simple dilatation of the intestinal tube, and will hold without distention 
only about an ounce of fluid. Vomiting easily ensues by a sort of regur- 
gitation, without nausea, when overfilling takes place, by simple contrac- 
tion of the walls of the tube. 

The Intestines. The small intestine is not uniform in its length at 
birth, hut measures, on an average, a little more than nine feet. The 
Large intestine measures not quite two feet, and is distinguished in the 
new-born by the greater relative length of the lower part of the colon. 

The Liver. The liver at birth is of relatively large size, being greater 
in bulk than both lungs, and containing much blood. The large size and 
importance of the liver in foetal life will be understood by considering it 
a sort of intermediary organ between the placenta and the general circu- 
lation, as far as the re-oxygenated blood is concerned. At birth the com- 
munication between the placenta and the liver and portal vein, by means 
of the umbilical vein, is severed by cutting the cord. The lungs at once 
inflate and assume the respiratory function. The umbilical vein begins 
to shrink, and is completely obliterated between the second and fifth 
days of life. It is finally reduced to the fibrous cord known as the round 
ligament of the liver. The ductus venosus is usually obliterated within 
a few days after birth. Although the liver has now lost its preponder- 
ating importance in the economy, it still remains relatively larger and 
heavier than in later life. The diminution of the organ is due to its 
altered blood-supply, and is especially marked in the left lobe. The loss 
of weight that begins at birth continues from infancy to old age. 

The digestive juices are imperfectly secreted in the new-born. Saliva 
is present in some degree with slight proteolytic power; the gastric juice 
is fairly active, but the pancreatic secretion does not attain physiological 
potency for several months. The intestinal glands are likewise in a low 
stage of development. The bile is poor in cholesterin, lecithin, fat, the 
special bile acids, and in inorganic salts. It is, hence, not difficult to 
understand the feeble digestive powers of early infancy, and the necessity 
for the greatest care in the administration of nutriment. 

The Urinary Organs. The pelvis is shallow; its inclination is exagger- 
ated, and its capacity is small. The bladder is largely an abdominal 
organ. 

The Kidneys. The kidneys are embedded in loose, fatty tissue, low 
down in the abdominal cavity, covered only in front and on their exter- 
nal borders by peritoneum. They are relatively of large size, and are 
distinctly lobulated. Crystals of uric acid often form in the calyces and 
in the pyramidal portions of the kidney during the first few days of life, 
and may produce considerable disturbance by their presence. The supra- 
renal capsules are also of large size, sometimes completely covering the 
kidneys. 

The Bladder. The bladder when distended is oval or egg-shaped in 
form, without a marked fundus, and it lies principally in the abdomen. 
The muscular wall is relatively very thick and dense, so that in female 
infants the bladder may be mistaken for the uterus on autopsy. In the 
female the urethra is placed along the anterior wall of the vagina, and 
its meatus appears almost as large as the orifice of the vagina. Confu- 
sion is sometimes encountered in passing a catheter unless this fact is 
borne in mind. Urination may take place at birth or a few hours after, 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 269 

when the fluid is clear and light colored, or it may be delayed for twenty- 
four hours, when its appearance is apt to be deep yellow aud turbid. 
Sometimes when the urine is surcharged with uric acid and the urates, 
yellowish or red deposits are left upon the napkin, which the attendant 
may mistake for blood. The daily amount of urine is scanty during 
the first three days, or before the free secretion of milk; it increases very 
rapidly during the next few days. Its average specific gravity is from 
1005 to 1010. 

The Skin. The skin of the new-born infant is soft and red, and covered 
with very fine hairs called lanugo, which are shed during the first few 
weeks. The sebaceous are more active than the perspiratory glands. 
Immediately after birth, the whole surface of the body is covered with 
sebum, with which are mixed epithelial cells and lanugo. 

The Lymphatics. The lymphatics are abundant and large in size in 
young infants, having a very free communication with all parts of the 
body. 

Growth. The infant loses in weight during the first two or three days 
following birth, but after this there should be a steady increase in growth. 
According to Dr. Money, after the fourth day the body gains in weight 
at the rate of three ounces for the second week, four ounces for the third, 
five ounces for the fourth, and during the second month an ounce a day 
is about the proper rate of increase. The average weight at birth, of 
well-developed infants, varies from seven to eight pounds. The muscles, 
which are feebly developed in the new-born child, increase rapidly in 
size and strength. The average length of the male infant at birth is 
about 50 centimetres, and of the female, about 49 centimetres. 

MANAGEMENT. 

Respiration. The first care of the attendant, after the delivery, is to 
see that respiration is established. The mouth should quickly be cleansed 
of mucus or blood, and the infant placed on its back or right side. If 
it does not breathe at once, respiratory efforts may be provoked by such 
simple measures as blowing on its face, a few smart taps with the hand 
upon the buttocks, or sprinkling with cold water. If the child draws 
three breaths during the first minute, it may usually be left to itself. 
Should it fail to breathe, examination is made to see if the heart is pul- 
sating. If it is, the cord is severed and artificial respiration maintained 
as long as the cardiac pulsations can be felt or until spontaneous respi- 
rations are regularly established. For the methods of performing arti- 
ficial respiration, the reader is referred to the Treatment of Asphyxia of 
the New-born. 

Ligation of the Cord. As soon as respiration is established, the cord, 
in the absence of navel cord hernia, is firmly ligated at a distance of 
about one-half to one inch from the cutaneous line. The ligature should 
be aseptic, strong, and of sufficient size to prevent cutting into the walls 
of the vessels. The cord is then cut with clean scissors about one-half 
inch from the ligature on the placental side. It is unnecessary to apply 
two ligatures and cut the cord between them, as is sometimes recom- 
mended, except in case of twin births. By allowing the blood to escape 
from the placenta, its volume is reduced and its delivery rendered easier. 



270 PHYSIOLOGY OF Till: PUERPERUM. 

When the cord is unusually large, a part of the gelatinous portion may 

be Btripped away, lest it retard desiccation, and l>y shrinkage loosen the 

Ligature. If the first Ligature does not entirely arrest the oozing of 

blood from the cut end of the cord, another should he applied nearer 
the hody. 

The Bath. The child is now wrapped in a previously wanned blanket 
or flannel. If much time has been consumed in establishing respiration, 
it may he well to place it in a basin of warm water for a few minutes, to 
warm its extremities and stimulate its circulation, before wrapping in 
the blanket. The water should not be warmer than 100° F. Care is 
necessary to avoid too much exposure of the new-born infant during the 
first few hours of its life. If its circulation is feeble, or if it seems 
weak or chilly, the first bath should be postponed, and its body heat he 
conserved by wrapping in cotton, with a shawl or blanket outside of this. 
Usually the cleansing may be proceeded with as quickly as possible. 
The bathing should be done in a warm room. During the process the 
infant should be protected from chilling. The sebum can easily be 
removed by covering the skin with a bland oil, such as lard or vaseline, 
applied with the hand. Gentle friction may be necessary when the 
cheesy mass is tenacious. When the whole body has been freely and 
systematically anointed, the surface may be cleansed with soap and water; 
finally the infant is immersed in water at a temperature of about 95° F. 
It is then enveloped in a large towel and dried. Great care should be 
observed in thoroughly cleansing the eyes and mouth. For this purpose 
a saturated solution of boric acid or borax in water may be used. The 
eyes are to be thoroughly cleansed of all vaginal secretion by allowing 
the solution to drop from absorbent cotton that has been saturated with 
it. After this irrigation, small masses of matter still adhering may be 
removed by mopping the lids with the cotton. A careless and free use 
of soap is sometimes responsible for irritated or inflamed eyes. The 
mouth may next be gently washed out with a soft rag wet with a similar 
solution. 

Care of the Cord. The stump of the cord, after being cleansed and 
dried, should have an extra ligature applied if required for safety, and 
then be wrapped in absorbent cotton. Mummification of the stump is 
the chief object of the navel dressing. The application of oil or powder 
to the stump is to be omitted, since these agents tend to prevent rapid 
desiccation. The time-honored dressing of linen rag with a hole cut 
in the centre, through which the stump protrudes, is permissible. The 
stump when dressed is laid flat on the abdomen with the cut surface 
directed to the left, and kept in place by the ordinary belly-band. 
The cord usually separates in from four to seven days. AVhen it drops 
a small superficial ulcer is left that should soon heal. This also is to 
be kept dry. 

Examination of Child. Before the bath, a careful inspection of all parts 
of the body should be made to detect possible malformations. This 
should include the head, mouth, neck, chest, abdomen, spine, anus, and 
genital organs. A rectal injection may be employed to make sure that 
the rectum is pervious. 

The Clothing. After the bath the child is dressed. The belly-band 
may consist of light merino in summer and soft flannel in winter, reach- 



THE NEW-BORN CHILD AND ITS MANAGEMENT 271 

ing from the axillae to the hips. It should not be applied too tightly 
for fear of embarrassing the movements of respiration. No general rule 
need be given in respect to the exact amount and character of the cloth- 
ing. Two things, however, are essential : It should be sufficiently warm, 
as tested by feeling the child's hands and feet, and it must be loose 
enough to allow free play for movements of the hands and feet, and 
for respiration. During sleep the sides of the head and the neck and 
shoulders may be covered with a light shawl. It is, however, un- 
necessary, if not harmful, to cover the face so as to interfere with a proper 
supply of fresh air. 

Maternal Nursing. After the mother has rested for six or seven hours, 
the infant may be applied to both breasts. This helps to establish the 
habit of suckling, and stimulates the mammary glands and the uterine 
contractions in the mother. No other food should be permitted except by 
special direction of the medical attendant. 

If there are reasons why the child should not be put to the breast at 
this early period, a teaspoonful of warm sterile water may be given at 
intervals of an hour or two if it is restless. The administration of 
water as a routine practice is useful for flushing the kidneys. It should 
be remembered that the new-born infant is unprepared for digestion, and 
feeding is likely to do harm. 

The mother, as a rule, should nurse her own infant. Natural nursing 
for the first nine months is so essential to the child's well being, especially 
in large cities, that nothing short of necessity should prevent it. Barely 
malformations of the nipples, depressed or retracted nipples, or exten- 
sive fissures may make nursing difficult or impossible. 

To obtain the best results the greatest possible regularity in nursing 
must be observed. The child should not, as a rule, be allowed to nurse 
oftener than once in two hours during the day, and four to six hours 
during the night. In its own interest and that of its mother the child 
should not sleep in the bed with the mother, but in a crib. It is im- 
portant for the mother's health, as well as for the quality of her milk, 
that she have six or seven consecutive hours of sleep at night. 

One of the commonest causes of trouble comes from nursing the infant 
whenever it cries, for the purpose of quieting it. This is one of the most 
frequent sources of acute and of chronic infantile indigestion. Violent 
emotional paroxysms on the part of a nursing mother may so modify 
the milk as to produce acute indigestion or severe nervous disturbance 
in the infant. Convulsions, acute diarrhoea, collapse, and even death, 
have been known to result from this cause. Colic and indigestion in 
the infant are sometimes due to digestive derangements of the mother. 

The infant should suckle the breast for about fifteen minutes at each 
nursing, and then fall asleep. If it is unsatisfied and fretful, after nursing 
for that length of time, there is probably insufficient milk in the breast. 
The breast milk may fail either in quantity or quality. If too little 
is secreted, stimulation of the gland and a generous diet are indicated. 
The most natural stimulation comes from the application of the infant at 
comparatively frequent intervals; yet a long interval is sometimes allowed 
with the mistaken idea that rest may enable the gland to better fulfil its 
functions. 

A generous supply of nourishing and easily digested food is indicated. 



272 PHYSIOLOGY OF THE PUEBPEBIUM. 

Oatmeal gruel, thin and well cooked, has a reputation for promoting the 

milk secretion, which seems to have some foundation. The liberal use 

of cow's milk lias also a like effect. Malt liquors, Buch as ale or porter, 
by Stimulating the appetite, may indirectly aid in the production of milk. 
The digestion and assimilation of the nursing mother often suffer for 
want of proper exercise, with the effect of impairing the quality and 
Lessening the quantity of milk. Regular exercise in the open air must 
he advised as soon as circumstances permit. 

It must not be forgotten that the mammary gland may act as an excre- 
tory as well as a secretory organ. This is especially true at the beginning 
of the lactation period, when great care must be exercised in giving 
drugs that may be excreted in the milk and affect the infant. Alcohol, 
opium, and belladonna are known to be thus eliminated in amounts 
sufficient to produce appreciable effects upon the infant. 

Contraindications to Maternal Nursing. Most mothers prefer to nurse 
their offspring, and the physician should encourage adherence to the 
natural method of feeding in the absence of a definite contraindication. 
The following are the conditions which most frequently prevent or forbid 
nursing : 

1. Depressed, or otherwise deformed nipples; 

2. Diseases of the nervous system in general; 

3. Epilepsy, when the seizures come oftener than twice a year; 

4. Hysteria, especially after a pronounced hysterical disturbance; 

5. Certain constitutional diseases, such as tuberculosis or syphilis; 

6. Chronic diseases of the skin, such as eczema, prurigo, psoriasis, etc. ; 

7. Caries and chronic joint diseases; 

8. Chronic rheumatism; 

9. Advanced cardiac or renal disease; 

10. Puerperal fever continuing more than two or three days; 

11. Metrorrhagia when prolonged, since it has a very deleterious effect 
upon the composition of the milk. The appearance of the regular men- 
strual flow is not a contraindication to nursing unless the child shows 
signs of disturbance at the epochs; 

12. Pronounced anaemia not easily corrected by treatment; 

13. Abnormal milk, when it disturbs the digestion of the infant, and 
when it cannot be corrected by changes in the mother's diet or faulty 
habits. 

Mother's Milk is a secretion of the mammary glands, consisting of an 
emulsion of fat suspended in a clear transparent liquid, in which sugar, 
caseinogen, lactalbumin, certain extractive matters and inorganic salts 
are dissolved. A good normal mother's milk has a bluish- white appear- 
ance, is more tranpsarent than cow's milk, and has a sweeter taste than 
the latter. It is neutral or slightly alkaline, frequently amphoteric in 
reaction, and has a specific gravity of 1026 to 1036. When examined 
under the microscope, the milk globules will be found to vary greatly in 
size; each is surrounded with a layer of more or less viscid material, which 
prevents them from running together. According to Woll, 1 c.c. contains 
1.6 million globules, from 0.0024 to 0.0045 mm. in diameter. 

During the first eight or nine days after parturition, and sometimes 
later, the milk contains characteristic, larger bodies, known as colostrum 
corpuscles. These appear to be composed of masses of protpolasm con- 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



273 



taining fat. The colostrum corpuscles are four to five times as large as 
the fat globules. (Fig. 210.) They may occur in milk at any later 
time during the lactation period, and are then to be regarded as evidence 
of illness in the mother, or of pregnancy. Occasional colostrum cor- 
puscles in the milk have little or no significance, but if present in 
considerable number they are liable to cause digestive derangement in 
the child. 

Normal milk has the appearance seen in Fig. 211. In taking a 
sample of milk for microscopic examination, it should be drawn after 
the child has about half emptied the breast, and not at the beginning 
or end of the nursing. The microscope is often of value in showing 



Fig. 210. 



Fig. 211. 




Colostrum corpuscles. 



Normal human milk. 



the presence of blood, pus, or other foreign elements, but it is of little 
value as a guide to the richness of the milk, on account of the difficulty 
in securing a sample that represents the average secretion of the breast. 
The length of time the milk has remained in the breasts exerts an im- 
portant influence upon the number of globules it contains. The longer 
the period of retention the more watery it becomes, probably from ab- 
sorption of the solid parts. On the other hand, milk that is frequently 
taken from the breast is thicker from being richer in solids. 

Abnormal Mother's Milk. It occasionally happens that an apparently 
healthy mother secretes an abnormal milk that disagrees with the infant. 
The constituents most subject to variation are the fat and the proteids. 
Our knowledge of the causes of these variations is, unfortunately, im- 
perfect. Rotch and Adriance find that a diet rich in nitrogenous matter 
tends to increase the fat in the milk, while an abundance of fat in the 
food tends to diminish it. Excess of proteids is usually more troublesome 
than any other abnormality. Rotch also pointed out that an over-liberal 
diet, with little exercise, may increase the proteids in the milk; a less 
generous diet, with abundant out-door exercise, may correct this abnor- 
mality. Marked emotional disturbance frequently increases the proteids 
temporarily and causes colic in the nursling. 

18 



274 



PHYSIOLOGY OF Till- PUERPERIUM. 



The following table of variations in human milk, from Rotch, is of 
interest in this connection : 

Normal. Poor. Very rich, Dad Milk. 

Normal exercise Starvu- Generous diet. Pregnancy. 

and food. tton. Little exercise. dlaeaae, etc, 

I-'nt 4.0 1.50 5.10 0.80 

Protelda 1.2 2.40 4.60 

Sugar 7.0 4.00 

ieh 0.2 0.09 0.09 

TotalBOlldd . 12.13 7.99 16.35 LG\8fl 

Water 87.87 92.01 83.65 89.61 

100 100 100 100 

When there is reason to believe that the mother's milk is not agreeing 
with her infant, an excess of casein should be suspected, and an analysis 
by a chemist may reveal the fault if it lies in the milk, and point out 
the way to its correction. It is advisable in all such cases to examine 
carefully into the mental and physical habits and characteristics of the 
mother. 

The daily amount of milk secreted by the average mother, and the 
weight of each feeding and of each constituent at different periods of 
lactation, are given in the following table from Pfeiffer : 

Table I. 



Age of infant. 



1 month. 

% week 

1 " 

2 weeks 

3 " 

4 " 

2 months. 

5- 6 weeks 
7- 8 " 

3 months. 

9-10 weeks. 
11-12 " 

4 months. 

13-14 weeks 
15-16 " 

5 months. 

17-18 weeks 
19-20 weeks 

6 months. 

21-22 weeks 

7 months. 

25-28 weeks 

8 months. 

29-32 weeks 

9 months. 

33-36 weeks 



Total 
amount in 
grammes. 



104 
254 
334 
449 
550 

749 



926 
896 



974 

996 
996 

1023 

1051 

741 

482 



Number and 
weight of 
each meal. 



7 X 
7 X 



13 

36 
48 
68 
71 

107 
123 



X 132 
X 128 



138 
139 



142 
142 



167 
174 



6 X 

6 X 

6 X 124 

6 X 88 



Proteids 


Fat 


in 


in 


grammes. 


grammes. 


4.40 

8.74 

7.64 

10.27 

12.58 


2.81 

6.86 

12.13 

12.13 

17.86 


13.82 
15.83 


22.52 
26.40 


17.68 
17.10 


20.43 
20.25 


19.53 

19.62 


39.02 
39.23 


17. 38 
17.42 


52.36 
52.28 


15.82 


26.88 


15.99 


34.77 


12.15 


28.69 


7.26 


11.62 



Sugar 

in 

grammes. 



4.69 
11.44 
15. 05 
20. 23 
24.78 

41.47 
45.03 

55.28 
53.50 

59.12 
59.39 



60.00 
60.40 
42.80 
28.94 



The foregoing results were obtained by weighing a series of infants 
before and after each nursing, and adding the weights of all the feedings 
for the twenty-four hours. The weights of each constituent were obtained 
by calculation from the known composition of the milk as determined 
by chemical analysis. It will be noted that the quantity of milk secreted 
increases gradually from the beginning of lactation until about the tenth 
week, then remains practically stationary until the sixth month, when it 
increases somewhat, and finally decreases. Human milk varies consider- 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



275 



ably, both in quality and quantity, in different individuals, and even in 
the same individual, because of varying physiological and pathological 
conditions relating to food, nutrition, duration of lactation, length of 
time the milk remains in the breast, exercise, menstrual function, emo- 
tions, and nervous affections. 

It is, therefore, very difficult to arrive at the normal composition of 
human milk, since these disturbing elements have not been taken into 
account in most of the published analyses. Analyses of human milk by 
different chemists differ widely, and it is difficult as yet to determine the 
typical normal standard. In general, it may be stated that during the 
first week of lactation, colostrum is secreted, containing less fat and sugar 
than normal milk, more proteids (the greater part of which is lacto- 
globulin and lactalbumin), and more salts. 

The fat and sugar rapidly increase after the eighth day till the end of 
the first month; from that time the proportions of these ingredients 
remain constant until about the eleventh month, when they fall off. 
The proteids and salts exist in much larger percentages in colostrum 
than in normal milk, the former containing on an average 2.5 to 3.5 per 
cent, of proteids and 0.4 to 0.5 per cent, of salts. Both these constituents 
gradually diminish until the eleventh month, when they again slightly 
increase. During the first month of lactation, human milk contains 
between 1.5 and 2.5 per cent, of total proteids; during the second about 
2, and in the third about 1.5 per cent. 

The percentage of iron falls off as lactation proceeds, and after the 
eighth or ninth month it becomes decidedly less than normal. The milk 
of the early months of lactation, then, is characterized by a large per- 
centage of proteids and salts, and a small percentage of sugar. That of 
the later months is characterized by a smaller percentage of proteids and 
salts, and a higher percentage of sugar. The smaller proportion of pro- 
teids and of iron in the later months contraindicates prolonged nursing. 
When children are nursed too long (beyond the eleventh month) they 
frequently show symptoms of malnutrition, and often become anaemic 
or rachitic. 

It is of interest to note that the composition of the milk varies greatly, 
according to the time it has remained in the breast. Forster gives the 
following analyses of the first, the middle, and the last portions taken 
from the breast during an ordinary nursing : 

First portion. Second portion. Last portion. 

Amount taken .... 33.1 c.c. 33.1 c.c. 37.3 c.c. 

Water 90.24 per cent. 89.68 per cent. 87.50 per cent. 

Proteids 1.13 " 0.94 " 0.71 

Fat 1.70 " 2.77 " 4.51 

Sugar 5.56 " 5.70 " 5.10 

Ash 0.40 " 0.32 " 0.28 

It is evident from the foregoing figures that care must be observed in 
obtaining a sample of milk for analysis, if we wish to secure results that 
are comparable or that will represent the real composition of the secretion. 
The middle portion only should be taken, after the child has nursed one- 
third of its usual time. These analyses also show that in too frequent 
nursing the child gets only " strippings," or over-rich milk, likely to 
disturb digestion. 



276 PHYSIOLOGY OF THE PUEBPEBIUM. 



Substitute Feeding. 

Wet-nursing. When, after proper effort, the mother is unable to nurse 
her infant, wet-nursing may he considered. 80 difficult is it to secure a 

good wet-nune that the uncertainties of this method are often scarcely 

than those attending artificial feeding. The expense, too, of sub- 
stitute nursing places it beyond the reach of the mass) 3. 

The moral character and social standing of most women who are will- 
ing to wet-nurse are Buch that many families shrink from taking them 
into their homes. While the clanger of the transmission of syphilis or 
tuberculosis by an apparently healthy nurse has been overestimated, it 
is, nevertheless, a real one, and no woman the subject of either of 
these diseases should be allowed to nurse an infant. There are many 
instances on record in which syphilis has been communicated in this 
way. 

While healthy breast milk is undoubtedly the best food for an in- 
fant, it is equally true that with a proper knowledge of the best modern 
methods of substitute feeding there is now little need of resorting to 
wet-nursing. 

Mixed Feeding. It frequently occurs that the mother is able only to 
partially nurse her baby. In such cases mixed feeding should be resorted 
to — L <?., the mother should nurse the infant at regular intervals, and the 
nursing should be supplemented by two or more artificial feedings in the 
twenty-four hours. The practice of nursing only at night, which is some- 
times advised, is objectionable. Regularity of nursing is essential to the 
continuance of the secretion. Mixed feeding may sometimes be rendered 
necessary by the transient illness of the mother, or a temporary defi- 
ciency occasionally resulting from unassignable causes or from nervous 
or emotional influences. In some instances the secretion may be restored 
by faradization of the breasts or by change of surroundings. 

Artificial, or Bottle Feeding. When good breast milk is not available, 
artificial food must be provided, and its preparation must be managed 
with scrupulous care. 

'A substitute food should fulfil the following requirements: (1) It should 
correspond in composition, digestibility, temperature, reaction, and quan- 
tity, as nearly as possible, to normal human milk. (2) Its preparation 
should be as simple and uncomplicated as possible. (3) It should not be 
expensive, and should be easily obtainable. The basis of an infant food 
must be milk, and in this country the only easily obtainable animal 
milk is that of the cow. In selecting the milk great care is necessary. 
It should be the mixed milk of a herd, and not that from a single cow, 
since the former is more nearly of constant quality. It should be as 
fresh as possible, and clean. Milk from grass-fed cows is to be pre- 
ferred. For use in large cities milk that has been bottled at the dairy, 
and subjected to the least possible amount of handling in shipping, 
is best. 

Difference between Human and Cow's Milk. To properly understand 
the modification of cow's milk for infant feeding it is obviously neces- 
sary to know what are the differences in the composition and properties 
between it and human milk. Some of the more important differences 
are shown in the following table: 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



211 



Human milk. Cow's milk. 

Percentage. Average. Percentage. Average. 

Water .... 83.69 to 90.00 87.09 80.32 to 91.50 87.41 

Solids .... 9.10 " 16.11 12.91 8.50 " 19.68 12.50 

Fat ... . 1.71 " 7.60 3.90 1.15 " 7.09 3.66 

Sugar .... 4.11 " 7.80 6.04 3.20 " 5.67 4.50 

Casein. . . . 0.18 " 1.90 1.03 1.17 " 7.40 3.50 

Albumin . . . 0.39 " 1 35 1.20 0.21 " 1.50 0.53 

Ash .... 0.14 ? 0.49 0.50 " 0.78 0.70 

Calories furnished by 100 c.c. (3.5 ounces) 69.00 67.00 

It will be seen that the range of variation in composition of both milks 
is very considerable. These variations include abnormal or pathological 
conditions, and will largely disappear when the mixed milk of several 
individuals is considered. Mixed cow's milk of good quality will not 
vary much in composition from that given in the column marked ' 'aver- 
age." When the averages of the two milks are compared, we observe 
that human milk is slightly richer in fat, one-third richer in sugar, twice 
richer in albumin, and contains one-third as much casein (precipitable by 
rennet), and a little more than one-half as much ash as cow's milk. The 
most marked quantitative differences are in the sugar and the proteids. 
The proteids are chiefly casein and albumin, although a small quantity 
of a peculiar globulin is also present. The casein, or that part of the 
proteids which is precipitated in the human stomach by rennin or by 
the gastric acid, is three or more times as great in cow's as in human 
milk. By reason of this, as well as differences in composition of the 
two kinds of casein, the curd of cow's milk is larger in amount, tougher 
in consistence, and less easily digested than that of human milk. Indeed, 
the casein of human milk is only partially precipitable by acids, and in 
some cases imperfectly by rennin. The soluble albumin in human milk 
is twice that of cow's milk. More than half the proteids of human milk 
remain in solution until they leave the stomach, while four-fifths of the 
proteids of cow's milk are precipitated in a solid curd soon after it 
enters the stomach. The relation between the quantity of lactalbumin 
and casein is a matter of great importance in determining the behavior 
of the milk when coagulated. In the presence of a considerable amount 
of soluble albumin the casein coagulates in fine flocculi, while without 
it these are much larger and show a tendency to collect in masses. 
The normal ratio between albumin and casein in human milk is nearly 
1 to 0.8, while in cow's milk it is nearly 1 to 7. Camerer gives the ratio 
in human milk as 1 to 0.6 during the first month. Monti has called 
attention to the fact that when the proportion of albumin to casein is dimin- 
ished, the infant generally suffers with digestive disturbance. The pro- 
portion of total proteids in human milk is greater during the first weeks 
of lactation than afterward, and the ratio of albumin to casein is greater. 
These differences in the composition of the proteids of human and cow's 
milk are too often lost sight of in attempts to adjust the latter to suit the 
digestion of the infant. These differences in composition and behavior 
of the proteids of the two milks explain why the the infant experiences 
so much difficulty in digesting cow's milk. But these are not the only 
differences in the proteids. Human milk contains, according to Siegfried 1 
and Stoklassa, 2 about 0.12 per cent, of nuclein, and about the same 

i Zeitschr. f. Phys. Chem., 1896, p. 576. 2 ibid., 1897, p. 343. 



27s 



PHYSIOLOGY OF nil-: it i:i:i>i:rium. 



percentage of Lecithin, including nearly all the phosphorus of the milk in 
this organic combination. Cow's milk contain- Less than half as much 
DUclein and lecithin. But one-half of the phosphorus <>f cow's milk is 
organic or tissue-building phosphorus. From what we know of the 

nutritive value of nuelein and lecithin, it woidd seem that cow's milk, 
even when l\>(\ in the undiluted state, cannot nourish an infant as well as 
human milk. Boiling or sterilizing destroys much of both the nucleic 
and lecithin of cow's milk, and greatly reduces the nutritive value of the 
milk. This will be referred to later in considering sterilized milk. 

Table II —Human and Cow's Milk Compared. 



Human Milk. 



Appearance Bluish, translucent, odorless, sweetish. 



Specific 
gravity 

Reaction 



Behavior 
on hoi ling 



1026 to 1036. 



Remains alka- 



Amphoteric or alkaline, 
line a long time. 

Does not coagulate, but forms a 
slight film of albuminoid matter. 



very 



Cow's Milk. 



White, opaque, odor, and slightly sweet 
taste. 

1030 to 1036. 



Amphoteric or acid. Rapidly becomes 
acid in the air. 

Does not coagulate, but forms a thicker 
film consisting of casein and lime salts, 
which, when removed, is rapidly re- 
newed. 



Coagulation Coagulates at ordinary temperature after Coagulates much earlier than human 

many hours. milk. 

Coagulation Coagulates incompletely in fine flocculi, Coagulates at body temperature, and sep- 

with rennet which never precipitate in distinctly arates into distinct masses, leaving a 

visible masses. supernatant yellowish liquid. 



Fat . . 



Relation of 
fatty acids 



Casein 



Composition 
of proteids 



Mineral 
matters in 
ash 

Bacteria . 



Yellowish-white, similar to cow's butter ; 
specific gravity at 15° C. = 0.966 ; melts 
at34°C. Composition : butyrin, caproin, 
caprin, myristin, palmitin, stearin, and 
olein. 



Relatively poor in volatile acids; of the 
non-voiatile acid sone-half is oleic ; of 
the remainder, myristic and palmitic 
predominate. 

Precipitated with difficulty by acids and 
salts ; the precipitate dissolves easily 
in excess of acids. In peptic digestion 
it leaves little residue. Contains little 
Ca 3 (P0 4 ) 2 . 

Albumin 1.1 per cent., casein 1 per cent., 
globulin 0.1 per cent., albumin to casein, 
1 to 0.8 io 1 to 2. 100 c.c contain 0.175 
gramme lecithin and 0.120 gramme nu- 
elein. Nearly all the phosphorus is in 
organic combination. 

K.,0 NaoO CaO MgO Fe 3 Po0 5 CI 
780 0.232 328 0064 0.001 473 0.43S 
contains less ash than cow's milk. 

Generally sterile. Exceptionally a few 
staphylococci albi and s. aurei. 



Yellowish-white mass, specific gravity at 
150 c.= 0.996 ; melts at 35.8° C. Composi- 
tion : butyrin, caproin. caprin, palmi- 
tin, stearin, olein, myristin, caprilin, 
laurin, arachin, leucitin, cholesterin, 
and yellow coloring matter. 

The volatile acids relatively large. Of the 
non-volatile acids, 3 to 4 per cent, is 
oleic ; the remainder is a mixture of 
principally palmitic and stearic. 

Easily precipitated by acids and salts; 
precipitate not easily dissolved by excess 
of acids. In pepsin digestion it leaves 
considerable residue. Contains more 
Ca 3 (P0 4 ) 2 than human milk. 

Albumin 0.53 per cent., casein 3 per cent., 
globulin trace, albumin to casein 1 to 6 
to 1 to 10. 100 c.c. contain 0.110 gramme 
lecithin and 0.055 gramme nuelein. Less 
than half the phosphorus in organic 
combination. 

K,0 NaoO CaO MgO Fe«0 3 P0O5 CI 
1.72 510 1.98 0.200 0.003 0.820 0.980 
Contains more ash, especially CaO and PO 

Contains all milk bacteria, and occasion- 
ally typhoid, diphtheria, tubercular, 
and other bacteria. 



Modified Cow's Milk. The above-described differences between human 
and cow's milk make it necessary to modify the composition of the latter 
to render it available for infant feeding. No modification yet known, 
however, will bring cow's milk to agree in composition with human 
milk or make it a perfect substitute for the natural food. The modifi- 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 279 

cations of cow's milk that are most frequently practised are the fol- 
lowing : 

1. Simple dilution with water; 

2. Dilution with gruels, such as barley, oatmeal, corn-starch, wheat- 
flour; or with gelatin, gum arabic, egg albumin, or sugar-water; 

3. Dilution with water, or sugar-water, and the addition of cream; 

4. Partial creaming, using the upper half, including the cream, and 
adding sugar-water and lime-water; 

5. Removing a part of the casein by means of rennin or by the cen- 
trifugal machine; 

6. Partial peptonizing of the proteids, and dilution with water; 

7. Mixtures of milk, cream, sugar, and water, made according to chem- 
ical analysis, to contain a known percentage of each constituent. 

Dilution with water, to the extent required by the excess of proteids in 
cow's milk, reduces the fat and sugar below the proportion necessary for 
the nutrition of the infant, and such modification alone is seldom suc- 
cessful. 

Dilution with barky-water, oatmeal- water, gelatin-water, etc., have 
for their object the reduction of the proportion of coagulable proteids, 
and the mechanical division of the curd by the starch, mucilage, and 
extractives, thus causing the curd to be more easily disintegrated and 
more readily digestible. Considerable doubt has recently been thrown 
upon the claim that the curd is more readily digested as the result of 
mechanical division by such means. Such admixtures have the disad- 
vantage that they add substances that are foreign to the natural food. 
It is well known that young infants have very feeble digestion, and 
when farinaceous material is added to their food it is apt to create diges- 
tive disturbance. 

Rational Method of Modifying Cow's Milk. The only rational and prac- 
tical household method of modifying cow's milk for infant feeding is to 
dilute the milk so as to reduce the casein to 1 per cent, or less, then to 
add cream to bring the fat up to 3 or 3.5 per cent., and milk sugar to 
bring it to 6 per cent. The simplest and most practicable method of 
doing this is as follows: 

When the milk is received it is allowed to stand in a cool place for 
three hours. The top third, or half, including the cream, may then be 
poured off and used for making the food. When the milk is received in 
bottles, as is now the custom, it is better to remove the bottom milk by 
means of a siphon, consisting of a piece of small rubber tubing about, 
eighteen inches long, leaving the cream layer and top milk undisturbed 
in the bottle (Fig. 212). The tube is first filled with water, and both 
ends are held firmly between the thumb and forefinger of the left hand. 
One end is pushed through the cream to the bottom of the milk bottle, and 
the other is lowered into a suitable receptacle. On releasing the pressure 
the milk flows from the bottom of the bottle into the receptacle. 

When two-thirds of the contents of the bottle are thus drawn off, the 
remaining portion will have approximately 7.5 to 8 per cent, of fat, 4 
per cent, of proteids, and 4.5 per cent, of sugar. 

When one-half of the milk is thus drawn off, the remainder will have, 
when shaken up, about the following composition: Fat, 5 to 6.5 per 
cent. ; proteids, about 4 per cent. ; sugar, 4.5 per cent. 



280 PHY8I0L0QY OF THE PUEBPEBIUM. 

Id cither case the ricb milk Left in the bottle is to be diluted with 
enough sterilized water t<> bring it up to the volume of the original milk. 

When two-thirds of the original milk have been drawn off, and the 
remaining one-third has been diluted with enough Bterilized water to 
make it up to the original volume — i. c, twice its volume of water — the 
mixture will contain about 2.(j percent, of fat, 1.2 per cent, of proteids, 
and l.o per cent, of BUgar. To bring the BUgar up to () per cent, will 
require the addition of one and a half ounce or three heaping table- 
spoonfuls of milk BUgar to a quart of the mixture. The sugar should !)«■ 
dissolved in the water, with the aid of gentle heat, before this is added 
to the rich milk in the bottle. These percentages meet the require- 
ments of most infants for the first few months. 

Fig. 212. 



- 

I 

w iH 



; ■: V- ■■■■ \ V .'••/MSfflEy 



Method of siphoning off the under milk. 

When one-half of the original milk has been drawn off and the remain- 
ing portion thus diluted, the mixture will contain about 2.5 to 3.2 per 
cent, of fat, 2 per cent, of proteids, and 2.2 per cent, of sugar. To 
increase the sugar in this mixture to 6 per cent, will require the addition 
of two and a half heaping tablespoonfuls of milk sugar to the quart of the 
diluted milk. This latter preparation will usually be found suitable for 
infants of five months or more. 

When it is desired to increase the fat and reduce the casein, this may 
be done by drawing off the under three-fourths or more of the original 
milk, diluting the remaining portion with two or three times its volume 
of water, and adding milk-sugar, about thirty grains to each ounce of 
the mixture. This may frequently be found necessary when feeding 
very young infants or those with feeble digestive power. For such cases, 
however, the mixture of rich milk and whey, described below, is to be 
preferred. By these simple methods it will be possible to instruct the 
nurse or mother to prepare a food which will agree with most children, 
provided the original milk is of good quality. 

It is advisable to Pasteurize the mixture, especially in warm weather. 

It is a common practice to add about one-twentieth volume of lime- 
water, before feeding, to secure an alkaline reaction. 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 281 

It will occasionally be found, even with a food in which the casein has 
been reduced, by one of the above methods, to one-third or one-fourth 
that found in cow's milk, that curds will appear in the stools of the 
infant. In such cases a little white-of-egg water added to the food may 
promote the disintegration and digestion of the curds. 

In some cases partial 'peptonization may be necessary. This is accom- 
plished by the following process : To a pint of the milk add 5 grains of 
extractum pancreatitis and J 5 grains of sodium bicarbonate. Warm the 
milk slowly to 104° F., and keep it at that temperature for ten minutes, 
then bring it nearly to the boiling point, to destroy the ferment. In- 
stead of heating the milk to the higher temperature, it may be placed 
at once on ice. Peptonization may do good for a short time, but expe- 
rience has shown that it is rarely well borne when long continued. It 
seems better to allow the digestive juices of the infant to accomplish 
the necessary changes in the food than to induce them outside of the 
body. If predigestion is practised at all, the process should not be car- 
ried beyond a partial digestion. This principle applies with equal force 
to all the predigested or partially digested foods of the markets. Expe- 
rience has shown that none of them are successful except for a time. 

Disadvantages of Gravity Cream. The results obtainable with the 
mixtures above described will be better, as a rule, than with home-made 
mixtures of milk, cream, and water, because the best obtainable cream, in 
large cities, is usually decidedly acid and teeming with milk bacteria. 
This is especially true of gravity cream. Preparations made with such 
cream are very liable to produce acid fermentation in the infant's stomach, 
with vomiting. Centrifugal cream, when fresh, has the advantage that 
it is usually fairly uniform in composition, and may be obtained of 
known fat contents. It has the disadvantage that the natural emulsion 
is broken up by the process of separation, the fat globules being collected 
in small lumps. The fat is, consequently, less easily digested by the 
infant. This objection is a serious one when the cream is kept some time 
after the separation, before using. 

Vigier's Method. A method of preparing a close imitation of human 
milk, suggested by Yigier in 1893, is as folows : Divide a quart of milk 
into two equal portions. Let both stand three or four hours in a cool 
place, skim the cream from one portion and add this to the other. To 
the skimmed portion add a teaspoonful of liquid rennet, or of Fairchild's 
essence of pepsin; warm to 35° to 40° C. (95° to 104° F.) for fifteen 
to twenty minutes, with frequent stirring, or until it forms a tough curd. 
Then heat to 68° C. (155° F.) and strain through muslin and cool. 
The whey so prepared from good milk will contain, of casein, 0.03 per 
cent.; albumin, 0.80 per cent.; fat, 1 per cent.; sugar, 4.5 per cent., 
and salts, 0.70 per cent. It contains a little more soluble proteid than 
the milk from which it is prepared. For infants under five months of 
age, mix equal volumes of this whey and the enriched milk; for infants 
over five months, mix two parts of milk with one of whey. The com- 
position of this food will be nearly as follows, expressed in percentages : 





Casein. 


Albumin. 


Fat. 


Sugar. 


Salts. 


Equal volumes of whey and milk 
Two parts milk and one part whey 


. 1.22 
. 1.61 


0.66 
0.61 


2.33 
3.11 


4.5 
4.5 


0.7 
0.7 



Average human milk . . . 1.03 1.20 3.90 6 04 0.4 



282 PHYSIOLOGY OF THE PUEBPEBIUM, 

The close resemblance of this mixture to human milk is seen by com- 
parison. Except for a Blight deficiency in sugar the similarity is striking. 

Milk-sugar is easily added, if desired, in the proportion of 18 grammes 
(one heaping tablespoon! ul) to the quart of food. This is first dissolved 

in the hot whey before mixing it with the milk. This mixture will, if 
properly made, correspond more nearly in composition to human milk 
than any other known to the author. One very important consideration 
in regard to this food is the relation between the casein and the lactalbu- 
min, which, while it is not exactly that of human milk, corresponds more 
nearly to it than can be attained by any other method of dilution. This is 
very important in its effect on the consistence of the curd. This mix- 
ture, when coagulated with acid, behaves very strikingly like human milk. 
The fat has not been removed from the milk and, therefore, the emulsion 
has not been destroyed, as is the case in all mixtures made with cen- 
trifugal cream. In large cities, where much of the milk is served in 
bottles, in which the cream has already separated, it is better to siphon 
off the lower half or two-thirds, as described on page 279, and treat 
this with the rennet, adding the resulting whey to the upper half or 
upper third. 

Gartner's Milk. Gartner, of Vienna, has recently placed upon the 
market a milk containing one-half the normal proportion of casein in 
cow's milk while retaining nearly the full percentage of fat. 

The relation of albumin to casein in this milk is as 1 to 7, or the same 
as that obtained by diluting milk with an equal volume of water. The 
milk, then, has nearly the following composition, expressed in percent- 
ages: Casein, 1.75; albumin, 0.27; fat, 3; sugar, 2.25, and salts, 0.35. 
Its reaction is faintly acid; its specific gravity is 1020 to 1025, and it 
has a pleasant, though feebly sweet taste. The latter defect is met by 
the addition of milk-sugar. It coagulates with acid in finer flocculi 
than cow's milk, and has been used with some success in infant feeding. 
It has the disadvantage that the relation of soluble albumin to the casein 
is that of cow's milk, and not that of human milk. In this respect it is 
inferior to the mixture of whey and milk above described. It has the 
further disadvantage that the fat globules conglomerate into masses, 
which cannot afterward be emulsified again, rendering the fat difficult of 
digestion. It is supplied in the markets in tin cans, like condensed milk, 
and is previously sterilized by heat. It, therefore, has all the disadvan- 
tages of sterilized milk, mentioned under that heading. 

The Mechanical Method of modifying milk consists in adding thin gruels, 
made with the cereal grains or dextrin, to cow's milk. They attenuate 
the clot of casein, so that it becomes more flocculent, like that of woman's 
milk. Barley-water is most commonly used for this purpose. The only 
disadvantage in giving it to very young infants is due to the starch it con- 
tains. Before the third month, owing to the fact that the salivary and 
pancreatic glands are slightly developed, very little starch can be digested. 
Most of the prepared infant foods contain too much unchanged starch for 
a young infant's digestion. What is desired is a flour containing the 
albuminoid constituents of the grain, carbohydrates, in soluble form, 
and but little of the insoluble starch. As a result of a series of experi- 
ments carried out by Drs. Eiloart and Chapin, a simple process was 
arrived at, by which in any kitchen a cereal food may be made contain- 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 283 

ing three-fourths of the solid matter in a soluble form, and having more 
or less sugar (maltose) as desired. Their process is as follows : Beat one 
heaping teaspoonful of barley or wheat flour with half a medium-sized 
coffee-cup (J pint) of cold water, until perfectly free from lumps. Add 
this to one and a half cup (j pint) of boiling water in the inner vessel of 
a double boiler; stir well, cover and cook for ten minutes by keeping the 
water boiling in the outside vessel. Take out the inner vessel and add at 
once one and a half cup (} pint) of cold water, then add half a teaspoon- 
ful of malt extract, stir thoroughly with the same teaspoon, cover, and 
let stand for fifteen minutes; then put the inner vessel back into the boil- 
ing water in the outer vessel, and cook for fifteen minutes. If the child' s 
bowels are loose, use two cups of boiling water instead of one and a half, 
cool off with one cup of cold water instead of one and a half, and let stand 
three minutes instead of fifteen. As cow's milk is usually slightly acid, 
while human milk is neutral or alkaline, it is well to add some weak 
alkali to correct the acidity of the food. Lime-water is most commonly 
used, in the proportion of one ounce, or less, to the pint of food. 

Sterilized Milk. In all large cities, and whenever cow's milk cannot 
be obtained "fresh from the cow" twice a day, it is necessary to 
adopt some means of checking the fermentative changes in it. Ex- 
periments show that cow's milk when first drawn from the udder, 
under the usual conditions, contains from forty to several hundred bac- 
teria in each cubic centimetre. After six hours it contains from 5000 to 
10,000 in each cubic centimetre. These bacteria multiply very rapidly, 
producing detrimental changes in the milk, unless their growth is checked 
by a very low temperature, by the use of antiseptics, or by the application 
of heat. The well-known process of sterilization consists in heating the 
milk to 100° C, 212° F., for a sufficient time to destroy the bacteria 
and most of the spores of bacteria without producing too great changes 
in the taste of the milk. In practice, the time of heating varies from 
fifteen to forty-five minutes. Complete sterilization can be accomplished 
only by heating the milk to 110° C. for fifteen minutes. 

This sterilization at 100° C. produces the following changes in the 
milk, which are undesirable: 

1. A part of the sugar is decomposed or caramelized, giving the milk 
a disagreeable taste; 

2. The fat is melted, the emulsion largely destroyed and rendered less 
digestible; 

3. The casein is changed, so as to be less easily affected by rennet, and 
when coagulated it forms tough indigestible curds, which may be found 
in the stools; 

4. The albumin and globulin are coagulated, and made capable of 
precipitation with the acids of the gastric juice, thus increasing the size 
and toughness of the curd formed in the stomach, and making it less 
easily digestible; 

5. The nuclein and lecithin of the milk are largely destroyed, and the 
peculiar nutritive function of these bodies is lost. It is probable that this 
is the cause of the loss of antiscorbutic properties in sterilized and in 
condensed milk; 

6. The salts are rendered more insoluble; especially is this true of the 
phosphates. 



284 



rilYSIOLOGY OF THE PC FAIPERIUM. 



Children fed exclusively upon sterilized milk fail to thrive as well 
a> when fed upon unsterilized milk, and show a tendency to develop 
rachitis. 

The advantages of sterilized milk are: 

1. The destruction of disease germs; 

2. The prevention, to a great extent, of the accidents due to sour milk ; 

3. The increased keeping quality of the milk, without ice, and on long 

journeys. 

Pasteurization or Partial Sterilization at a temperature not exceed ing 
70° C, 158° F., has now practically superseded complete sterilization. 
Most proteids coagulate at 73° C. to 75° C, 163.4° F. to 167° F., while 
lactalbumin coagulates at 77° C, 170.6° F. The temperature should 
not, therefore, be allowed to reach 77° C, 170.6° F. This temperature 
is above the thermal death-point of the lactic-acid ferment and of most 
pathogenic organisms. The bacillus tuberculosis, the bacillus typhosis, 
bacillus diphtheria^ and bacterium lactis are all killed by fifteen minutes' 
exposure to a temperature of 65° C, 149° F. 



Fig. 213. 



Fig. 214. 





Freeman's Pasteurizer. 



Arnold's milk sterilizer. 



The simplest and most practical Pasteurizer in the market is that 
devised by Dr. Freeman, of New York, Fig. 213. It consists of a 
tin pail provided with a groove to indicate the amount of water to be 
added. The water is heated to boiling on an ordinary cooking-stove. 
The milk, contained in bottles plugged with cotton, is placed in the zinc 
cylinders of the rack, the space about them filled with water, and lowered 
into the boiling water, the cover put on, and the pail removed from the 
stove. The latent heat of the water is just sufficient to heat the milk to 
about 68° C, 154.4° F., when all the bottles are filled. After half an 
hour the cover is removed, the rack containing the bottles is raised partly 
out of the water, and cold water run into the pail until the milk is cold. 
This process will greatly increase the keeping quality of the milk with- 
out perceptibly changing its chemical properties or taste. Arnold's milk 
sterilizer, too, may be used with satisfaction for Pasteurizing. (Fig. 214.) 

Condensed Milk. Condensed milk has been a popular food for infants 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 285 

ever since its introduction. The canned milk which contains cane- 
sugar added as a preservative is most commonly used. The makers 
claim that such milk is condensed to one-fourth the original volume, 
but analysis shows that it is usually condensed to one-third — i. e., when 
diluted with two volumes of water it will give a liquid containing the 
same percentages of milk-solids as the original milk, together with about 
12 to 13 per cent, of cane-sugar. Meigs has shown that when one part 
of the best commercial sweetened condensed milk is diluted with nine 
parts of water, the mixture somewhat closely corresponds in composition 
with human milk, with the exception that it is deficient in fat and con- 
tains cane-sugar for a part of the lactose. A mixture of one part of 
condensed milk, one part of Pasteurized cream (containing 12 per cent, 
of fat), and eight of water, more closely resembles human milk in com- 
position. While many infants will apparently thrive on this mixture, it 
has all the disadvantages of sterilized milk, and infants fed upon it almost 
invariably show signs of rachitis sooner or later. 

Milk Laboratories. During the past few years milk laboratories have 
been established in some of the large cities, with the object of securing 
greater accuracy in the artificial feeding of young infants. The Walker- 
Gordon Company were the pioneers in this field, and are now operating 
laboratories in New York, Brooklyn, Philadelphia, Boston, Chicago, 
Baltimore, and Montreal. The physician writes directions for an infant's 
food, and sends them to these laboratories, just as he orders drugs by 
prescription. 

It is found that slight changes in the percentages of fat, sugar, and 
proteids may be of great value in managing cases of indigestion and 
malnutrition in the infant. The following is Dr. Rotch's working basis, 
deduced from the study of normal average breast milks for the first three 
months of life. It must be understood, however, that these figures may 
require modification to suit individual cases. 

i. ii. in. iv. v. 

Fat 2.00 2.50 3.00 3.50 4.00 

Milk-sugar .... 5.00 6.00 6.00 6.50 7.00 

Albuminoids .... 0.75 1.00 1.00 1.50 1.50 

Mineral matter . . . . 0.11 0.17 0.17 0.25 0.25 

Total solids . . . .7.86 9.67 10 17 11.75 12.65 

Water 93.14 90.33 89.83 88.25 87.25 

The following may be giveu as a sample prescription to be tried for a 
new-born infant after the second day: 

Fat 2 per cent. 

Sugar 5 " 

Proteids 0.75 " 

Lime-water 5 " 

Number of feedings 10 

Put up in ten bottles, each containing one and a half ounce. Pas- 
teurize at 167° F. for fifteen minutes. 

Should this mixture agree the sugar and fat should be increased at the 
end of the first week by one-half per cent. The sugar may be increased 
to 6 per cent, at the end of the second week, unless the child has colic. 
It is not always easy to determine the cause of the disagreement, but a 
few trials with varying percentages of fat, proteids, and sugar will enable 
the practitioner to adapt the food to the needs of the individual case. 



286 physiology OF THE PUEBPEEIUM. 

It will seldom be necessary to depart from the known variations in 
human milk, as given in the table <>n page -74. 
Too large a percentage of Bugar may cause greenish, acid stools and 

colic, and too low a percentage will usually lead to dry stools and 
failure of the proper increase in weight. 

Too large a percentage of fat may give rise to vomiting, diarrhoea, and 

fatty masses in the stools. In some cases an excess of fat may cause 
colic. A deficiency of fat frequently occasions constipation, with dry, 
hard stools. The fat should rarely be increased above 4 per cent., and 
it is seldom that more than 3.5 per cent, is necessary. 

An excess of casein is the most frequent cause of digestive disturbance 
in bottle-fed infants. The casein should never be more than 1 percent. 
to begin with, and in most cases less than this will be found to give the 
best results. 

The most certain indication of too large an amount of casein is the 
presence of curds in the stools. It must be remembered that free fatty 
acids so closely resemble curds as to deceive the naked eye. In such cases 
the stools are strongly acid, and they irritate the nates and genitals, caus- 
ing erythema. These lumps of fat or fatty acids are soluble in ether, 
while the casein lumps are insoluble in that reagent. 

Sometimes the child is unable to digest even a very small amount of 
casein. 

We have already called attention to the importance of a proper rela- 
tion between the percentages of albumin and casein. The addition of a 
small amount of egg-albumin to the food will sometimes assist in the 
digestion of the casein. If we attempt to correct the proteids of indi- 
gestion by reducing the proportion of albuminoids, the child may suffer 
for want of nitrogenous food. 

It is to be remembered that human milk contains about 2 per cent, of 
proteids, while colostrum, according to Pfeiffer, contains 9 per cent, of 
proteids on the first day after parturition, 7 per cent, on the second day, 
and 2.36 per cent, on the eighth day. Heubner gives the percentage 
of total proteids during the first week as from 2 to 3.2 per cent. Nearly 
the whole of these proteids is in the form of albumin and globulin, 
while the milk prepared at the milk laboratories contains but a trace of 
albumin. It is this large proportion of albumin to casein in human milk 
that prevents the firm coagulation of casein. 

While the introduction of milk laboratories has given us valuable 
assistance in the feeding of infants, it will be seen from the above facts 
that the mixtures they place at our command still lack a very important 
feature, as regards the proteids, to make them resemble human milk. 

The term albuminoids in the above table might with propriety be 
changed to casein, for the reduced proportion is secured by diluting 
cow's milk, which contains about 0.5 per cent, of albumin. To reduce 
the casein to 1 per cent, the milk, and consequently the albumin, must 
be diluted three and a half times with water. This will reduce the albu- 
min in such a mixture to 0.1 per cent. 

If we Avish to make the casein of cow's milk behave, on coagulation, 
like human casein, we must dilute the milk with five parts of water, 
thus reducing the casein to about 0.6 per cent. This proportion of 
proteid is too small to afford a proper amount of nitrogenous food for 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



287 



the child. Egg-albumin is sometimes used to supply soluble albumin 
to the milk foods. The author has seen good results from this addition 
to modified milk. Egg-albumin is different in composition and pro- 
perties from lactalbumin, and raw-egg albumin does not seem to digest 
as readily as lactalbumin. Whether these facts contraindicate its use 
cannot be stated with certainty. Experience has not demonstrated the 
unfitness of fresh egg-albumin water as a diluent in modifying milk. 

The objections to the use of centrifugal cream have already been stated. 

We may repeat here the statement that a process for preparing an 
exact substitute for mother's milk has not yet been devised. 

The Nursing Bottle. One of the most important points in artificial 
feeding is scrupulous cleanliness of bottle and nipple. The long rubber 
tube connecting the bottle with the nipple must be discarded, and the 
bottle itself should be as round and tube-like as possible, to avoid angles 
in which sour milk may collect. The nipple should be a simple rubber 
cone with several very small openings at the end. These openings should 
require suction on the part of the infant to bring out the milk. If, upon 
inverting the bottle, milk streams through the nipple, the latter is unsuit- 
able for use; the fluid runs too freely into the infant's stomach, and 
indigestion is likely to result. Both bottle and nipple must be scalded 
after using, and when not in use be kept in a solution of soda or borax 
and water, or some mild antiseptic solution. 

Amount and Frequency of Feeding. The amount of fluid to be given at 
each meal and the interval between meals are matters of great importance. 
Irregular and hap-hazard feeding should not be countenanced. The phy- 
sician should direct these matters as minutely as possible, giving detailed 
directions as to the preparation of the food, its preservation until needed, 
the kind, size, and form of bottle, and the amount and time of feeding. 

In breast-feeding the quantity of fluid taken is determined by the 
quantity secreted, and usually regulates itself. Sometimes, however, the 
amount secreted is too great for the needs of the infant, and at others it 
is not enough. In bottle-feeding the tendency is to feed too much and 
too often. Overfeeding is much more harmful than underfeeding, and 
is the most frequent cause of gastro-intestinal disturbance in bottle-fed 
infants. The capacity of the stomach in infancy is subject to consider- 
able variation, but, as a general rule, the gastric capacity of a child 
during the first month is one-hundredth the child's body- weight — i. e., 
the greater the weight the greater the gastric capacity. Numerous 
measurements of the stomach -capacity of infants, by different observers, 
as well as practical experience, have shown that the amount to be given 
at each feeding, the intervals between feedings, and the number of feed- 
ings in each day, are about those set forth in the following table. It 
must be understood, however, that these figures may need to be modified 
to suit individual cases : 







No. of 


Amount 


Amount 


Age. 


Interval. 


feedings 


of each 


in 






in 24 hrs. 


feeding. 


24 hours. 


First week, 


2 hours. 


10 


1 ounce 


10 ounces. 


1 to 6 weeks, 


2 


10 


1% to 2% ounces. 


15 to 24 ounces 


6 to 12 «• 


2% " 


8 


2K to sy 2 « 


20 to 28 


3 to 6 months 


2% to 3 hours. 


6 


4 to 5% 


24 to 32 


6 to 9 " 


3 hours. 


6 


6 ounces. 


36 ounces. 


9 to 12 " 


3 


5 


8 


40 



288 1'llYSIOLOLiY OF THE PUEBPEBIUM. 

Gavage, or Forced Feeding. It becomes necessary at times to feed an 
infant, or even older children, by the forcible introduction of food into 
the stomach through a tube Although this method of feeding has been 
practised fora longtime in Borne Buropeau countries, its advantages have 
not until recently been lullv appreciated in this country. 

The method of practising gavage is very simple. The apparatus used 
is the same as that for stomach washing, and consists of a soft-rubber 
catheter, 12 to 16, American scale, or 24 French scale, a small funnel, 
two feet of rubber tubing, and a piece of glass tubing about three inches 
long to connect the rubber tubing to the catheter. The child is placed 
upon its back, the catheter is quickly introduced, the funnel raised so as 
to straighten the rubber connecting tube, and the food poured into the 
funnel. As soon as the food has almost all run down, the tube is 
pinched, to prevent the milk from trickling into the pharynx as the tube 
is removed, and it is then quickly withdrawn. The child should be kept 
absolutely quiet after feeding by this method. Should it offer much 
resistance to the introduction of the tube, the latter may be passed 
through the nose. In older children a mouth-gag is often necessary. 
If the food is regurgitated or vomited, the tube should be introduced a 
second time, and another feeding given. The intervals between feedings 
are generally longer when gavage is practised than under other circum- 
stances. When this method is employed in feeding premature or feeble 
infants, the food should usually be predigested; if the mother's milk can 
be used this is unnecessary. It is well to wash the stomach before the 
first feeding, and at least once a day afterward while gavage is practised. 

In connection with the incubator gavage has been found of great 
advantage in feeding premature infants; also after operations upon the 
throat and nose, and in other conditions in which the child may refuse 
food. The food is not often vomited when thus introduced, even when 
not retained in the usual method of feeding. 

Signs of Normal Nutrition. The best index of the nutrition of an infant 
is the rate of iucrease in weight. The study of the child's nutrition 
requires frequent weighing. The weight of the average infant at birth 
is, according to J. Lewis Smith, seven pounds and four ounces for girls, 
and seven pounds and eleven ounces for boys. Others place the weight 
slightly lower, with less difference between the sexes. During the first 
three or four days there is a loss in weight of six to ten ounces, which is 
regained by the middle of the second week. A loss of twelve ounces, 
or a failure to regain the birth-weight by the beginning of the third 
week, at the latest, calls for careful investigation. 

After the second week the weight should increase regularly, the child 
doubling its birth- weight by the end of the fifth month. While the rate 
of increase differs very considerably, a child that is not gaining five 
ounces a week cannot be said to be thriving as it ought. The accom- 
panying chart, from Holt, shows the rate of increase in weight of the 
average well-nourished infant during the first year. (Fig. 215.) 

The Feces. The character and amount of the stools of an infant often 
give an important indication of the quantity of food taken and the degree 
of digestion. They also give valuable information as to the cause of loss 
of weight and the character of the digestive disorder. 

The stools of the new-born infant are greenish-black in color, and are 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



289 



termed meconium. Meconium is composed of intestinal mucus, bile, 
vernix caseosa, epithelium cells, hair, fat, cholesterin crystals, and cal- 
cium and magnesium phosphates. It is free from bacteria immediately 
after birth. On the third to the fourth day the stools change to a lighter 
color, and by the fifth day are lemon-yellow. 



Fig. 215. 

























WEEKS 


OF 


AGE. 


























GRMS. 


w 


1 


2 


4 


6 


8 


10 


12 


14 


10 


18 


•20 


22 


21 


26 


28 


30 


32 


31 


36 


3S 


40 


42 


44 


46 


48 


50 


52 


9070 


20 
























































8620 


19 
























































8160 


18 
























































7710 


17 
























































7260 


16 
























































6800 


15 
























































6350 


14 
























































5900 


13 
























































5440 


12 
























































4990 


11 
























































4540 


10 
























































4080 


9 
























































3630 


8 
























































3180 


7 
























































2720 


6 
























































2270 


5 
























































1810 


1 

























































Normally the stools at this time are from three to four in twenty- 
four hours, smooth, semi-solid in consistence, nearly homogeneous in 
appearance, and have a slightly acid, not unpleasant odor. They con- 
tain fat, free fatty acids, calcium lactate, and a small amount of casein. 
The reaction of the feces is usually acid, but is sometimes neutral or even 
alkaline. The cause of the acidity is the presence of fatty acids, lactic 
acid, and sometimes butyric. The degree of acidity varies considerably, 
yet excess of lactic and butyric acids may be considered pathological. 
The yellow color is due to bilirubin. 

In diseased conditions the stools often become green, which color is 
usually attributed to biliverdin, but there is some doubt upon this point. 
Opposed to this idea is the fact that the stools are often yellow when 
passed, but become green on exposure to the air, while biliverdin on 
oxidation yields bilirubin, which is yellow and not green. In some 
cases at least the green color appears to be the result of fermentative 
processes, and to be caused by the excessive production of lactic acid and 
the action of this upon the biliary coloring matters. 

There will usually be found with the green-colored stools more or less 
undigested casein and free fatty acids. These appear as white masses 
distributed through the feces. Fat may be distinguished from casein by 
its solubility in a mixture of alcohol and ether. 

The normal stools of a nursing infant contain about 85 per cent, of 
water, 2 to 3 per cent, of fat, 0.2 per cent, of proteids, and 0.1 to 0.2 per 
cent, of cholesterin. 



19 



290 PHYSIOLOQ? OF THE PUEMPEBIUM. 

Excessively acid stools often irritate the oates and genitals, producing 
a troublesome erythema. 

Hie Btoolfi of infant- fed upon cow's milk do not differ materially 
from those of breast-fed children, except that the amount is miieh 
larger, and they are more liable to contain caseous masses of large size, 
especially when sterilized milk is used. 

Dry and pasty >t<>ol> or an insufficient amount of fecal matter are 
often indications of a deficient supply of food. An excessive quantity 
of fecal matter is usually the result of overfeeding. 

Starch will often be found in the stools of infants fed upon cereal food-. 
Its presence may readily be shown by its blue color reaction with iodine. 
Mucus is contained in the stools in catarrhal enteritis or intestinal in- 
fection. 

A careful inspection of the stools should be made in all cases in 
which there is reason to suspect any form of digestive disorder. 

Care of Prematurely Born Infants. 

Infants born before term require greater care than full-term children. 
Those born before the sixth month rarely if ever live. Of those born 
during the sixth month, a small proportion have sufficient vitality to 
survive, with proper care and attention. The prognosis will vary with 
the degree of prematurity and the development of the child. When 
but a few weeks are lacking to complete the full term, little extra care 
may be necessary. It is well, however, in such cases to omit the usual 
bath, apply a liberal coating of sweet oil to the skin, after washing the 
face, and use extra precautions to keep the infant warm. If the circu- 
lation is good and the cry vigorous, the child may be dressed; otherwise, 
it should be wrapped in cotton, and all exposure and handling deferred 
until later. In some cases the infant may be so feeble as to require the 
application of artificial heat to maintain its vitality. This will be indi- 
cated by cold and cyanotic extremities, feeble cry, and inability to nurse. 

Incubators. Artificial heat may be applied by rolling the infant in 
blankets and placing a few bottles filled with water at a temperature of 
105° F. in the blanket with it. A much better method is the use of 
an incubator. In private practice the physician may be called upon to 
improvise an incubator. It is a matter of the greatest importance that 
whatever measures are to be adopted to supply heat, they should be 
utilized as soon as possible. A simple, practical incubator may be con- 
structed from a soap or candle box. Half-inch auger-holes are bored in 
the sides of the box about six inches above the bottom, and a pillow or 
other suitable bed is placed in the box, upon which the infant is laid, 
wrapped in cotton. The heat may be supplied by means of bottles filled 
with hot water and placed within the box. 

The author has used an improvised incubator constructed as follows : 
There is required first a packing-box of suitable size, about 18 x 24 x 10 
inches, and a piece of three-inch lead pipe, bent, as shown in Fig. 216. 
The longer arm of the pipe should be about the length of the box and 
the other a little shorter than its height. The end of the shorter arm is 
cut at an angle of sixty degrees. An opening is provided in one corner 
of the bottom of the box, larger than the pipe, and another in the oppo- 



THE NEW-BORN CHILD AND ITS 3IANAGEMENT 



291 



site end near the top and at the corresponding side of the box. (Figs. 216 
and 217.) The opening in the bottom of the box is covered with a plate 
of tin. The latter is provided with an opening large enough to receive 



Fig. 216. 




Incubator. Longitudinal vertical section. 
Fig. 217. 




Incubator. Transverse vertical section. 



292 



PHYSIOLOGY OF THE PUEB I'l.RIUM. 



the chimney of a kerosene lamp. The box is supported on two chairs, the 

pipe is put in place, with the Long arm projecting an inch or two from the 
end of the incubator, and the Bhorl arm resting upon the tin plate cover- 
in-' tin- hole in the bottom. The pipe is protected by a piece of wire 
netting, folded over it and tacked to the side of the box. A series of 
auger-holes are bored near the top edge of the sides and at one end of 
the box, to admit air, and a -lass plate is used to cover it. An ordinary 
kerosene lamp supplies the heat. The chimney of the lamp is passed 
through the hole in the tin plate, and well up into the pipe, so that no 
gases from the lamp can enter the box. The heat of the lamp creates 
a Btrong draught in the pipe, which not only carries off its own gases, 
but draws the air from the box through the open lower end of the pipe. 
The temperature of the air-chamber is regulated with a thermometer 
placed within by the side of the child. By raising or lowering the wick 
of the lamp the temperature can be raised or lowered, and can be adjusted 
to any desired degree. Moisture may be supplied to the air-chamber by 
hanging a wet sponge to the side of the box at any convenient place. 

AVhen once regulated it may safely be managed by any nurse, whether 
skilled or not. This is a matter of considerable importance in private 
practice. 

The temperature of the incubator for very feeble infants should be 
kept at about 35° C. to 37° C, 95° to 98.6° F. For those a little 
stronger it may 30° C. to 35° C, 86° F. to 95° F. 

Fig. 218. 




Incubator. (Holt.) 

An excellent incubator has been devised by Holt (Fig. 218). It is 
a modification of Tarnier's apparatus, and is less complicated and less 
expensive than many others that have been described. It consists of a 
double-w 7 alled box, thirty inches long, fifteen wide, and twenty high, with 
a one-fourth inch air space between the inner and outer walls. A tank 
of warm water, four inches deep and covering the bottom of the box, 
supplies the heat to maintain the requisite temperature. A loop of 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



293 



brass pipe is connected with one end of the tank, and this is provided 
with a funnel for filling and a faucet for emptying the tank. The water 
is heated by a Bnnsen burner placed upon a shelf under the loop of 
pipe. The tank holds five or six gallons of water. Fresh air is ad- 
mitted by four openings, three inches in diameter, two on each side of the 
box; a slide is so arranged as to regulate the admission of air at will. 
About six inches above the tank there is a shelf which serves as the 



Fig. 219. 
Glass Cover 




Vertical section of incubator, showing internal construction. (Holt.) 



support for the child's bed; a clear space of six inches is left at one 
end of the shelf. The air enters the openings above described, passes 
over the tank, then over a wet sponge and out at the top of the box. 
The internal construction is shown in Fig. 219. The top consists of a 
plate of glass, which may be pushed aside to admit of feeding the child 
without removing it from the incubator. The temperature is regulated 
by a thermometer. The infant lies upon a bed of cotton and enveloped 
in cotton. It is usually removed once daily for cleansing the chamber 
and renewing the cotton. 

Holt says there is some difficulty in maintaining good ventilation with 
the room temperature at 75° F. or higher, but none at 65° to 68° F. 

Kotch, of Boston, has devised a more complicated apparatus, but its 
expense is such that few will care to purchase it. 

The Feeding of a premature infant will require special care. If left 
to itself it will not nurse from the mother, or from a bottle, in many 
cases. It may be necessary to feed it with a medicine dropper, giving 
the food frequently and in small quantity at a time. When breast milk 
is available, it should be pumped from the breast and given every hour 
or two. Or, for the first thirty-six hours after the birth, a 5 per cent, 
solution of milk-sugar, or freshly prepared whey, made from cow's milk 
by coagulating it with rennet and straining through muslin, as directed 
under Artificial Feeding, may be given. When breast milk is not 



294 PHYSIOLOGY OF THE PUEBPEBIUM. 

available, whey may be exclusively given for the lirst week, and then it 

may be mixed with a little rich top milk, beginning with one-fourth rich 
milk, and gradually increasing this t<> one-third. When the child refuses 
to take sufficient food, as is frequently the case, gavage Bhould he resorted 
to. A half-ounce of breast milk may he given even- two hours to a 

seven months' child, and three-fourths of an ounce to an eight months' 
child. 

The usual period of incubation is from one to three months, but must 
be subject to the judgment of the physician in the individual case. It will 
depend upon the circulation of the infant and upon its power to main- 
tain its own body heat. AVhen it is desired to discontinue the use of 
artificial heat, it is well to first gradually reduce the temperature of tin; 
incubator, day by day, to that of the room. It will usually be unsafe to 
dispense with the incubator until the child begins to gain weight and is 
able to nurse at the breasts or the bottle. 

In many cases it will be advisable to keep the infant in the incubator 
until the period of full term has arrived. This, however, is not always 
necessary. 

The habit of nursing may be cultivated by feeding through a nipple- 
shield. 



PLATE XII 




Uterus with Two-egg Twins. (After Smellie.) 



PART V. 

PATHOLOGY OF PREGNANCY, 



CHAPTEE XII. 

MULTIPLE PREGNANCY. 

By multiple pregnancy is meant the development of two or more 
embryos within the maternal organism at the same time. While, as a rule, 
this takes place within the uterine cavity (Plate XII.), numerous cases 
are on record in which one embryo has found lodgement within the womb 
and another outside of it, combined uterine and extra-uterine gestation. 

The reason for the occurrence of multiple f cetation is not known, but 
speculation has given rise to many theories, the most plausible of which 
is that the condition is one of atavic manifestation. In its etiology the 
influence of heredity, especially on the mother's side, is well established, 
but instances of a paternal bias are not wanting. Conditions, such as 
climate, environment, and the like, appear to have little effect in deter- 
mining plural conception, yet in certain localities plural pregnancies 
occur with much greater frequency than in others. 

Rumpe found that in twenty-nine cases of single-egg twins the mothers 
were under twenty-five years of age in 70 per cent., and in one hundred 
cases of two-egg twins the mothers, were between twenty-six and thirty 
in 50 per cent. 

Frequency. Twin conception is more frequent in women who have 
already borne children, and more so in old than in young primigravidee. 
Of multiple pregnancies the commonest variety is twins ; triplets more 
rarely occur. Quadruplets, and even quintuplets, are met with excep- 
tionally. Eeported instances of a larger number of embryos developed 
simultaneously in the same woman have not been sufficiently authentic 
to merit credence. According to G. Veit, in 13,000,000 births, twins 
occurred once in 89, triplets once in 7910, and quadruplets once in 
371,126 labors. For this country these figures may be accepted as ap- 
proximately correct, though recent statistics from two of the largest 
Eastern cities place the proportion of twins at one in every 120 labors, 
while Green found three cases of triplets among 5626 labors (one in 
1875) in the records of the Boston Lying-in Hospital. 

Mode of Origin. Twins may arise (1) from a single ovum, the germ 
dividing, (2) from two separate ova developing in the same Graafian fol- 
licle — rarely, 1 (3) from two ova extruded from different portions of the 

1 While in the ovaries of the new-born child, and especially of the unripe foetus, a Graafian follicle 
is sometimes seen to contain two, three, or even four ova (Pantellani), Waldeyer states that in the 
adult human ovary he has never found more than a single ovum in a follicle. 

(295) 



296 PATHOLOGY OF PREGNANCY , 

Bame ovaiy, or I I) from two ova each proceeding from a different ovary. 
Triplets arise from three distincl ova, or from one-egg twins and a single 
ovum, while quadruplets come from double twins, or from twins and 
two single <>va. 

( )f twins those developing from two distinct ova arc the most frequent, 
and the combined average weight of such children is greater than in the 

case of Bingle-egg twins, while the difference in weight of the individual 
gemellus is more marked in the latter instance. This is probably due 
either to nutritive causes or to the inherent weakness of a divided germ. 

Sex of Twins. Veit found that of 150,000 twin pregnancies in rather 
more than one-third both children were males, in less than one-third both 
were females, and in the remaining third both Bexes occurred. The 
more recent statistics of Runipe show that of 65 single-egg twins, both 
children were males in 36, and both females in 29, and of 101 two-egg 
twins, in 31 both were males, in 16 both were females, and in 54 each 
sex was represented. This indicates that in about 66 per cent, of twins 
both children are of the same sex, with the proportion of males largely 
in excess. 

Arrangement of Membranes. The arrangement of the membranes in 
twin conceptions depends upon the origin of the embryos. The decidua 
vera is always single; the reflexa is single for one -egg twins, and double 
when two ova become attached at different portions of the uterine sur- 
face. The chorion is, also, always single when two embryos develop from 
the same egg y and double when two ova are involved. The amnion, an 
individual product, is probably always primarily double. AVhere two em- 
bryos occupy a common amniotic sac, the median wall, which originally 
separated them, may undergo absorption, and careful search will then 
generally reveal some vestige of its former presence. 

The Placenta. As the embryonic portion of this organ is always of indi- 
vidual origin, it follows that in all cases of twin pregnancy the placenta 
is at first double. But the close proximity of the two structures in one- 
egg twins usually leads to fusion of their contiguous edges, with subse- 
quent deep and superficial anastomoses of the bloodvessels; while, though 
a widely distant implantation of the placenta? may result in their per- 
manent separation, very frequently their borders will be found to have 
become united, with an easily recognizable intermediate zone lying be- 
tween. Whenever two chorions are developed anastomosis of the placental 
vessels does not take place. Placentae succenturiatce occur with frequency 
in twin pregnancies, as well as anomalies in the insertion of the placental 
end of the cord. 

The individual growth of twin embryos varies greatly, according to 
the proportion of blood supply furnished to each. Any interference 
with the circulation in the one — whether resulting from imperfect attach- 
ment, early partial separation from accidents to the placenta, anastomotic 
complications in joined placentas, inherent feebleness of the embryo, dis- 
orders of the membranes or the like — immediately acts to the advantage 
of the other; the latter, by its more rapid development and augmented 
strength, the expansion of its envelopes and increase of the surrounding 
liquor, soon acquires such supremacy over its fellow that this eventually 
perishes, and is either compressed and flattened against the uterine wall 
as a joetus papyraceus, degenerates into a mole, or is prematurely cast 



MULTIPLE PREGNANCY. 297 

off from the uterine cavity; the fortunate individual, on the other hand, 
continues to advance to the completion of gestation. It is estimated that 
the intra-uterine death of one embryo occurs with three times greater 
frequency in one-egg twins than in those developed from two separate 
ova, a circumstance readily accounted for by the fact that malformations 
and pathological conditions are much oftener met with in the former than 
in the latter. 

Superfoetation. In rare instances it has happened that the atrophied 
body of the dead foetus has been retained in utero for a considerable time 
after the expulsion of the living child at term. Occasionally, instead of 
perishing, the growth of the feebler embryo may be retarded only by the 
more rapid and vigorous advancement of the brother, and, after the 
delivery of the latter, may continue its intra-uterine existence for a period 
of weeks or even months until its development is completed. The fact of 
such a delivery following at an indefinite interval after the expulsion of 
the first child has led to belief in the possibility of superfoetation as 
opposed to superfecundation. 

Superfecundation. By the latter term is understood the fertilization of 
more than one ovum, discharged at the same ovulation, by separate acts 
of insemination at short intervals, while superfoetation implies the im- 
pregnation of an ovum during such time as another ovum from a pre- 
vious ovulation is in process of utero-gestation. While superfoetation 
is theoretically possible, it has not been proven. 

Pathological Character. Possibly owing to the excessive distention of 
the uterus as much as to other causes — hydramnios being a frequent 
accompaniment — there exists a marked tendency in plural pregnancies 
to an early termination of gestation, and miscarriage and premature 
delivery are particularly liable to result in cases of one-egg twins, quad- 
ruplets, and quintuplets. 

Both children in twin pregnancies may be expelled at the same labor, 
or at intervals ranging from eighteen to twenty-four hours, or even longer, 
as already mentioned. The offspring of plural pregnancies, are often of 
feeble vitality, and one child is quite likely to succumb within a com- 
paratively short time following delivery. Monstrosities are much more 
liable to be developed under these conditions, and the mothers are more 
prone to eclamptic attacks than when the pregnancy is simple. 

Diagnosis of Multiple Pregnancy. 

The existence of twin pregnancy may, as a rule, be determined with 
reasonable certainty by the following data : (a) Excessive size and ten- 
sion of the abdomen are significant of twins. (6) Permanent uterine 
tension with very limited mobility should suggest multiple foetation. 
Persistent tension is present in simple hydramnios, but here there is pre- 
ternatural mobility of the foetus. It also occurs in the concealed form 
of accidental hemorrhage, but the latter condition is distinguished by 
its shorter duration and by the signs of internal hemorrhage, (c) The 
abdominal tumor is usually broader than in single foetation. Some- 
times the abdomen presents a sulcus corresponding to the space be- 
tween the two foetuses; but this may arise from other causes. (d) 
Detection by abdominal palpation of two foetal heads, or of two dorsal 



298 PATHOLOGY OF PREGNANCY. 

l>l:m>'-, of three or four foetal poles, or <>f* a multitude of small parte is 
usually possible. (<■) Detection of one bead in the excavation and one 
in the upper uterine segment makes the diagnosis of twins. (/) One 

head may be found in the excavation and one in an iliac fossa. (//) Dis- 
tance from pelvic pole to fnndal pole more than 30.5 em., 12 Lncnes, is 

evidence of twins, [h) The recognition, by auscultation, of two Total 

heart-SOUnds, not synchronous, and heard at different locations, is con- 
clusive. It must not be forgotten, however, that one foetus may be 
dead. Even when both are living the detection of two independent 
heart-sounds is frequently impossible, (i) Suprapubic oedema is almost 
invariably present in plural pregnancy. This, however, may occur in 
single pregnancy with hydramnios, since it arises from venous stasis in 
the abdominal wall due to pressure brought about by the greatly dis- 
tended uterus. 

Vaginal Signs. During pregnancy twin foetation presents practically 
no characteristic signs obtainable by the vaginal examination. In course 
of the labor one or more of the following conditions may be detected. 
((() Kapidly successive presentation of a head and a breech. (6) Four 
extremities presenting, (c) Two amniotic bags offering at the cervix. 

The diagnosis of triplets is sometimes possible after the pregnancy has 
reached the later months. In quadruple pregnancy the existence of mul- 
tiple foetation should be capable of recognition, but the number of chil- 
dren can scarcely be determined before birth. 

Management of the Labor. The usual risks of labor for both mother 
and child are somewhat increased in twin births. The labor is fre- 
quently longer and is more likely to be complicated than in single foeta- 
tion. Owing to overdistention, the uterus may retract less promptly in 
the third stage, and the danger of post-partum hemorrhage is greater. 
The viability of the child is less than in normal gestation. In nearly 25 
per cent, of cases the labor is premature. These facts must be borne 
in mind in the management of the labor and the after-care of the 
children. 

According to the statistics of Klein wachter and of Speigelberg, in 50 
per cent, or more of twin births both foetuses present by the vertex. 
Breech and transverse presentations are more common than in ordinary 
labors. 

AVhen the first child is larger than the second, the second birth, as a 
rule, is rapid. The delivery of the second foetus is rarely delayed more 
than a few hours. The cord of the first child should be ligated on the 
maternal as well as the foetal side, owing to the possibility of communi- 
cation between the placental circulations. The membranes of the second 
foetus may be ruptured as soon as labor pains are resumed after expulsion 
of the first. 

Interference in either delivery must be governed by the same rules as 
in single births. 

Both placentas are usually expelled together after the birth of the 
second child. Very rarely, when the placentas are entirely distinct, the 
first one may come away before the expulsion of the second foetus. 

Special care will usually be required by manipulation and the use of 
ergot to secure full retraction of the uterus. 

In triple births the management is, in general, the same as in twins. 



CHAPTER XIII. 

ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 

For convenience, the subject will be discussed under the following 
subheads : 

Diseases of the Decidual. 

Anomalies and Diseases of the Amnion. 

Disease of the Chorion. 

Anomalies of the Placenta. 

Diseases of the Placenta. 

Anomalies of the Umbilical Cord. 



Diseases of the Decidual 

Probably most decidual diseases have their origin in endometritis, 
either acute or chronic. An acute endometritis may be lighted up in the 
early months of pregnancy, during the course of some of the infective 
diseases, as variola or typhoid fever. More commonly, however, the 
inflammation is antecedent to pregnancy. If the temperature is high, 
death of the foetus, with its subsequent expulsion, is likely to result. 
Two forms are observed, namely, a chronic diffuse endometritis or poly- 
poid degeneration, and a catarrhal endometritis or hydrorrhoea gravi- 
darum. 

(a) Chronic Diffuse Decidual Endometritis. In this form there is more 
or less hyperplasia of the connective tissue and of the subjacent muscular 
fibres. The disease affects the true decidua first. Cysts have been 
observed by Hegar and Maier. Parturition is often protracted in con- 
sequence of the slow separation of the decidua, and if the placental 
decidua is affected the placenta may be adherent. When the impreg- 
nated ovum becomes engrafted upon the inflamed mucous surface, the 
result is frequently rupture of some of the decidual vessels, with ex- 
travasation of the blood between the decidua and the uterine wall, and 
consequent abortion. 

If the inflammation is of a chronic character, the pregnancy may 
proceed to term. In the latter event the decidua is thickened and 
hypertrophied. Hofe has described deciduse in which old inflammatory 
processes caused small pedunculated excrescences, polypoid endometritis. 
Duncan holds that this hypertrophied condition is always accompanied 
with fatty degeneration, and that it occurs in cases in which the ovu m is 
retained after the death of the foetus. According to this authority the 
disease is characterized during pregnancy by painful movements of the 
foetus, accompanied at times with intense colicky pains, and which are 
aggravated by sudden chilling of the surface of the body, by muscular 
exertion, etc. Abortion is likely to follow as the result of the continued 
irritation or of a hemorrhage following such irritation. Should the preg- 

(299) 



300 PATHOLOGY OF PBEQNANOT. 

nancy go to term, difficulty may be encountered in the third Btage of 

labor by reason of undue adhesion of the placenta to the uterine wall. 
Virohow regards syphilis as the cause of the diseased condition of the 
deoiduaand of the pre-existing endometritis. 

At times the reverse of the foregoing condition obtains, and there is 
imperfect development of the decidna, particularly of the reilexa. The 
ovum, lacking its proper support, tends to fall away from the surface on 
which it was engrafted, and abortion is likely to result. 

(A) Hydrorrhoea Gravidarum. In chronic inflammation of the decidna 
there is frequently present not only proliferation of its cellular elements, 
but also increased secretion — hydrorrhoea gravidarum. This is character- 
ized by discharges from the uterus, varying in amount from a few drops 
to a pint or more, of a clear viscid liquid having sometimes a yellowish 
tinge and containing albumin. The discharge differs from the liquor 
amnii in containing neither urea nor vernix caseosa. Some writers speak 
of a spermatic odor, which, however, is not always observed. Hydror- 
rhoea occurs more frequently in multigravidae than in primigravidse. 

Diagnosis. Exceptional cases of this affection have been recorded as 
early as the third month, but usually it occurs toward the end of gesta- 
tion. First to attract the attention of the patient is the discharge of 
clear watery liquid from the vagina. There may be slight oozing for a 
few hours, or a pint or more may suddenly gush out, and the flow then 
cease. The discharge may occur at night while the patient is sleeping, 
during the last six or eight weeks of pregnancy. The discharges con- 
tinue at intervals of several days or possibly one or two weeks. The 
differentiation of this condition from a rupture of the amnion, with 
escape of the amniotic fluid, is of practical importance to the physician. 
In multipara? toward the end of pregnancy, the diagnosis is exceedingly 
difficult. The following questions are to be considered : Does the patient 
give a history of similar discharges during the preceding weeks? Is the 
os dilated, or are labor pains present? Does an examination of the dis- 
charge reveal vernix caseosa or meconium? 

Prognosis and Treatment. The prognosis is favorable so far as 
the life of the mother is concerned, yet if the amount of fluid discharge 
is excessive it may excite uterine contractions and end in premature 
delivery. In all cases rest in the recumbent position should be urged, 
and an anodyne be administered if the escape of fluid is accompanied 
with uterine contractions. Vaginal douches are injurious by causing 
irritation. No treatment yet advocated has the slightest influence on 
the production of the abnormal fluid. 

Anomalies and Diseases of the Amnion. 

(a) Oligohydramnios, or Deficiency of the Amniotic Fluid. Oligohydram- 
nios is a deficiency of the amniotic fluid. The cause of this condition is 
not known. With it are usually associated various deformities of the 
foetus which result from the undue pressure to which the foetus is sub- 
jected, and also from the constricting effect of the bands above described. 
The condition cannot be recognized before labor begins, and even were it 
possible, there is no treatment which would prove of value. The labor 
is apt to be tedious, from the fact that the child's head rests almost 



ANOMALIES AND DISEASES OF THE FOETAL APPENDAGES. 301 



directly upon the internal os, without the intervention of the fluid wedge, 
such as the amuiotic fluid usually forms. 

(6) Hydramnios, Polyhydramnios, or Dropsy of the Amnion is a true 
dropsy of the amniotic sac, in which the amount of fluid exceeds the 
conventional limit of four pints. It would seem more exact to restrict 
the term to cases in which the excess of fluid produces symptoms, since 
patients differ in their tolerance of excessive uterine distention. 

Frequency. From published cases one finds that this is a compara- 
tively rare disease, occurring once in 150 to 200 confinements. While 
this is a fair estimate of the frequency of cases in which the accumula- 
tion is rapid, it does not include a large percentage of cases in which the 
accumulation, though smaller, is yet sufficient to cause annoying symp- 
toms. Hydramnios occurs more frequently in multigravidse in the pro- 
portion of 2 or 3 to 5, and more frequently in twin pregnancies. 

Etiology. No explanation yet offered of the cause of this condi- 
tion has been generally accepted. Some authorities refer it to a previous 
inflammation of the amnion, others of the decidua. Playfair says that 
it is a true serous dropsy, resulting from some obstruction in the blood 
stream of the foetus, usually in the liver or the heart, whereby the 
placental supply is much in excess of the foetal requirements. The 
source of the liquor amnii as a physiological secretion has long been, a 
matter of dispute. Virchow's opinion is, that the fluid is a product of 
both mother and child, the former being a maternal transudation, and the 
latter composed of the vernix caseosa and renal secretions. Leopold 
holds that it is entirely a serous transudation through the chorion and 
the amnion, and is derived from the blood-current of the mother. Other 
authorities contend that it is produced solely from the foetus, either as 
an excretion from the kidneys and skin, or by a process peculiar to 
the amnion. Whichever view is accepted as regards the source of the 
fluid, we are still in doubt so far as the etiology of hydramnios is con- 
cerned. 

Symptoms. Hydramnios does not usually develop before the fifth or 
sixth month of gestation, though it may appear in exceptional cases as 
early as the eighth week. At times the first indication is nausea and 
vomiting, general malaise, loss of appetite, and more or less abdominal 
distress, or the pains may be intermittent in character and may closely 
simulate labor pains. There may be considerable prostration and ema- 
ciation, resulting from the patient's inability to retain nourishment. In 
the great majority of cases, however, the first sign to attract the patient's 
attention is undue enlargement of the abdomen. This is out of propor- 
tion to the period of gestation. At the end of the sixth month the 
uterus may reach the diaphragm. In consequence of this great disten- 
tion there is more or less oedema of the lower limbs, palpitation of the 
heart, and dyspnoea. Locomotion is painful, sometimes impossible. Dis- 
tinct fluctuation can be felt on palpation over the abdomen, which is 
scarcely possible in normal pregnancy at this period. The mechanical 
interference with the functions of the kidneys and liver may give rise 
to transient albuminuria or to icterus. The patient becomes anxious 
and nervous, is troubled with insomnia, and without relief may pass 
into a condition of grave peril. As the fluid increases in volume, the 
uterine walls as well as the abdominal walls are overdistended and 



302 PATHOLOGY OF PREGNANCY. 

thinned, There is preternatural mobility of the foetus. The foetal heart- 
Bounds arc Feeble or inaudible, the cervix is effaced, and upon vaginal 
examination the tense membranes may sometimes be felt t>v the examin- 
ing finger. Hemorrhage during pregnancy may occur from low implan- 
tation of the placenta, and the overdistention of the uterine muscle is a 
frequent cause of hemorrhage both during and after labor. 

Such i> a brief clinical picture of the majority of cases of hydramnios, 
hut the disease sometimes runs a more acute course, the abdominal dis- 
tention of the amnion occupying hut a few days, or at most a few weeks, 
and giving rise to profound systemic disturbance. In the presence of 
recurring chills a septic element is to be suspected. Fortunately nature 
often comes to the rescue by spontaneous rupture of the membranes and 
expulsion of the foetus. 

DIFFERENTIAL Diagnosis. Hydramnios is to be differentiated from 
twin pregnancy, ascites, hydrorrhoea gravidarum, and ovarian cystoma. 

In twin pregnancy the exaggerated size of the abdomen is present 
from the beginning, while in hydramnios there is no abnormal enlarge- 
ment till the fifth or sixth month, when there is a relatively abrupt 
increase in the size of the abdomen. Excessive tension is present in 
both, but in the latter there is preternatural mobility of the foetus, while 
in. the former mobility is wanting, or nearly so. In hydramnios the 
tumor is symmetrical in shape and nearly spherical, with, perhaps, its 
vertical diameter the greatest, while in twins the transverse diameter is 
longer; in the latter it is sometimes possible to map out the twin bodies. 
Two foetal heart-sounds, of different rates and in different parts of the 
abdomen, make the diagnosis of twins. In dropsy of the amnion but a 
single foetal heart is to be heard, and that indistinct and muffled. Bal- 
lottement and fluctuation, always obtainable in hydramnios, are not pres- 
ent in twins. It should not be forgotten that some degree of hydramnios 
generally exists with multiple gestation. 

In differentiating simple ascites from hydramnios, the presence or 
absence of pregnancy must first be established. In hydramnios the 
usual symptoms of pregnancy are present. Fluctuation in the tumor 
and oedema of the lower limbs are observed in both cases. In ascites 
the abdomen is usually more or less flattened at the umbilicus when 
the patient lies on the back. In hydramnios the enlargement, as 
already stated, is nearly symmetrical with no flattening at the um- 
bilicus, and the percussion note is tympanitic beyond the boundaries 
of the tumor. In ascites it is flat everywhere except, as a rule, at the 
summit of the tumor; even here resonance may be absent in exceptional 
instances when the mesentery is too short to permit flotation of intestines 
upon the fluid. The location of the tympanitic area changes with chang- 
ing positions of the patient. In hydramnios the relation of the flat aud 
the tympanitic area is but little affected by the position of the patient. 
Finally, ascites being only a symptom, the cause must be looked for in 
organic disease of the heart, liver, or kidneys. 

Hydrorrhoea gravidarum can scarcely be confounded with hydram- 
nios. Ovarian cystoma is distinguished from hydramnios by the history 
and by the physical signs. In the former the growth is gradual and 
usually covers a longer period. Menstruation is generally present. The 
fluid wave, as a rule, is more pronounced. Especially significant is the 



ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 303 

absence of foetal parts, of the foetal heart, and of active foetal movements. 
Ordinarily the uterus can be differentiated from the tumor on bimanual 
examination. Pregnancy complicated with ovarian cystoma may be mis- 
taken for hydramnios, but the two tumors cau usually be distinguished, 
one containing fluid, and the other presenting the usual characters of the 
gravid uterus. 

Prognosis. Hydramnios jeopardizes the life of the foetus. Nearly 
one-fourth the children are born dead or non-viable. As concerns the 
mother, the outcome is usually favorable. Cases of acute hydramnios, 
in which the maternal as well as the foetal life is seriously compromised, 
are very rare. The causes which increase the risk to the mother are : 
malposition of the child, overdistention of the uterus leading to hemor- 
rhages during and following labor, mechanical pressure caused by the 
enormous amount of liquor amnii, and, finally, increased liability to 
infection following abortion or labor. The dangers to which the foetus is 
subjected are premature expulsion, asphyxia, foetal malpositions, difficult 
labor, and malformations or immature development, which are frequent 
in hydramnios. 

Treatment of Hydramnios. In the chronic form of hydramnios, 
great relief is afforded by a properly fitting abdominal supporter and by 
comparative rest. In extreme uterine distention with grave cardiac dis- 
turbance the membranes should be ruptured. Interference, however, 
should be withheld, if possible, till the period of foetal viability. In the 
acute form the induction of labor is generally demanded. In puncture 
of the membranes the liquor amnii should be permitted to escape slowly, 
and the usual precautions must be observed to prevent syncope. It 
should be remembered that too abrupt evacuation of the fluid may lead 
to premature expulsion of the placenta. Uterine atony from overdis- 
tention exposes the patient also to post-partum hemorrhage. 

(c) Alterations in the Character of the Amniotic Fluid. During the early 
months of gestation, the liquor amnii is a clear, limpid, transparent fluid 
of low specific gravity, and perfectly odorless. As pregnancy advances 
the fluid becomes thicker, slightly unctuous, and contains small flakes of 
a whitish appearance, which are derived from the vernix caseosa. If 
the woman during this period be exposed to and is poisoned by certain 
substances, notably the mineral salts, as phosphorus, lead, and copper, 
traces of these substances will be found in the amniotic fluid. Meconium 
is frequently present during labor as the result of undue pressure upon 
the foetus. In cases of death of the foetus with subsequent maceration, 
the liquor amnii will be much thickened, of a dirty brown or greenish 
color, and of a fetid odor. 

(d) Amniotic Bands. The pathology of this condition is but poorly 
understood. Various theories have been advanced, none of which is 
wholly satisfactory. Some of the older authorities have considered these 
bands as organized lymph, resulting from a local inflammatory process; 
others, as prolongations of the skin of the foetus. Braun regards them as 
folds of the amnion. The absence of vessels in the amnion makes the 
theory of inflammatory origin impossible. Probably they result from 
adhesions of unknown origin between the foetus and amnion. This 
condition is liable to occur in oligohydramnios. As the amnion becomes 
more and more distended, traction is made on these points of adhesion, 



304 



PATHOLOGY OF PBEON [NOT. 



resulting in the formation of a hand. Such bands may encircle a limb 
of the child, and may thus result in spontaneous amputation of the 
girdled member. Various malformations, as webbed fingers and toes, 

hernia cerebri, dislocations and fractures, are attributed to these hands. 

Disease of the < Ihobion. 

Mxyomatous Degeneration of the Chorion. Hydatidiform Degeneration 
of the Chorion, or Vesicular Mole. This is the only disease of the chorion 
commonly met with. Freund, Gottschalk, and Runge have each reported 
cases of malignant disease of the chorion. Vesicular mole is character- 

FlG. 220. 







Vesicular mole. (Modified from Ribemont-Dessaignes and Lepage. ) 

ized by the presence within the cavity of the uterus of a mass of rounded 
vesicles varying in size according to the period of gestation, each one 
suspended by its own pedicle. (Fig. 220.) On close examination, some 
of the vesicles, instead of having a common point of origin, will be found 
attached to or springing from other vesicles. These bodies vary in size 
from that of a millet-seed to a hickory-nut, and are filled with a limpid, 
transparent, rarely reddish fluid, containing albumin, and much resem- 
bling liquor amnii. The disease is rare. It occurs most frequently be- 
tween the ages of twenty-five and forty years. 



ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 305 

Pathology. The degeneration of the chorion begins at an early 
period of gestation, usually not later than the tenth week. According 
to Braxton-Hicks, the following changes occur : the epithelium of the 
villi appears to be the part first affected; it undergoes a remarkable 
proliferation over the whole interior of the diseased villus and collects 
in masses at individual areas. By the growth of these elements the 
villus becomes distended, and many of the cells liquefy, the intercellular 
fluid thus produced widely separating the connective tissue, so as to 
form a network in the interior of the villus. Thus are formed the 
peculiar grape-like bodies which characterize the disease. This change 
may occur in but a small portion of the chorion, the nutrition being 
carried on successfully in the remaining unaltered portion. If the larger 
part of the chorion is involved, the foetus perishes. In twin pregnancies 
one chorion may be the seat of this degeneration while its companion is 
healthy. In exceptional instances the growth may be so excessive as to 
encroach upon the uterine wall, the mass becoming finally embedded 
within the muscular coats of the uterus. 

Etiology. The causative factor in this disease is still a matter of 
speculation. Virchow regards it as a diseased condition of the decidua 
resulting from a chronic endometritis. Certain English authorities hold 
that it follows the death of the foetus; others, that it depends upon some 
constitutional vice of the mother, as syphilis or tuberculosis. The prob- 
ability is that both foetal and maternal causes may, acting either together 
or independently, give rise to the disease under discussion. It is well, 
however, from the medico-legal stand-point to bear in mind the fact that 
true hydatids may be found in the uterus. It should also be remem- 
bered that in myxomatous disease the entire degenerated chorion, or 
portions of it, may remain in the uterus for months or years after impreg- 
nation. 

Symptoms. Certain vague, indefinite symptoms, such as abdominal 
distress, exaggeration of reflex phenomena, nausea, vomiting, and gas- 
tralgia, are mentioned by several authors, but none of the symptoms are 
of value for diagnosis. 

There are, however, three signs or symptoms of undoubted value; 
they are, in the order of their relative importance, as follows: First, and 
pathognomonic, is the expulsion of cysts from the vagina. This, un- 
fortunately, is seldom observed. In three carefully recorded cases no 
vesicles were found in the discharge until twenty-four hours previous 
to the expulsion of the entire mass per vaginam. Second, a more or less 
profuse sero-sanguineous discharge from the uterus, continuous or inter- 
mittent, resembling currant-juice. When the discharge is bright red, 
and occurs at intervals during pregnancy, the presence of placenta 
prsevia must be eliminated. Third, a sudden and rapid increase in the 
size of the abdomen, and in which the uterine enlargement does not 
correspond to the supposed period of gestation. This last symptom 
may be simulated by hydramnios, which must be excluded. The uterus 
presents a peculiar doughy feel, with an absence of foetal parts, of foetal 
movements, and of ballottement. Frequently the condition is detected 
only by intra-uterine examination. 

Prognosis. The prognosis in this affection is sometimes grave for the 
mother, and is generally fatal for the child. If only a limited portion of 

20 



306 PATHOLOGY OF PREGNANCY. 

the chorionic villi is affected, the foetus may survive and the pregnancy 
proceed to term. This is rare. The dangers to the woman arise chiefly 
from hemorrhage and septic infection; to the foetus, from interference 
with the proper blood-supply. 
Treatment. Immediately the diagnosis is established, the uterus, as a 

rule, should be emptied. Rarely it happens that the defeneration of the 
chorion is not extensive enough to kill the foetus, or that in twin preg- 
nancies one chorion may be affected and the other free from disease. 
The operator, therefore, must assure himself that the uterus does not 
contain a Living and viable foetus before interfering. The uterine contents 
should be removed little by little until the uterus is fairly well retracted. 
The remainder of the growth may then be brought away by a thorough 
curetting. To begiu with the curette would in most instances expose 
to perforation of the uterus, since the uterine walls are, as a rule, ex- 
tremely thin from overdistention. To completely destroy possible rem- 
nants of the pathological growth it is well to conclude the operation with 
an application of tincture of iodine over the entire uterine cavity. When 
this is done it is seldom possible that a second curetting will be required. 
Special precautions must be taken against post-partum hemorrhage. A 
half-drachm of fluid ergot should be injected under the skin before the 
patient is removed from the table. If required to prevent hemorrhage 
the uterus may be packed with iodoform gauze or with plain sterilized 
gauze. 

Anomalies of the Placenta. 

The anomalies of the placenta have for the most part a scientific 
rather than a practical interest. Those which occur most frequently, 
and which more directly concern the obstetrician, are anomalies of posi- 
tion, shape, size, and number. 

(a) Anomalies of Position. Normally the placenta is situated near 
the fundus of the uterus, either anteriorly, posteriorly, or laterally. 
Exceptionally it is implanted low down on the lower uterine segment or 
upon that portion of the uterus which becomes dilated during the first 
stage of labor. This condition is known as placenta prsevia. 

The subject is more fully considered under the Pathology of Labor. 

(6) Anomalies of Shape. The normal placenta is a round or oval 
disk-shaped body, thickest at the central portion, where the funis is 
usually inserted, and thinning toward the edges. The average measure- 
ments are tw r o to four centimetres in thickness at the centre, and from 
eighteen to twenty centimetres in diameter. Occasionally the outline is 
very irregular. In exceptional cases it has a crescentic or horseshoe 
shape. Rarely the umbilical cord is inserted at the margin — " battle- 
dore placenta." The placenta is said to be bipartite, multilobular, etc., 
when two or more cotyledons are excessively developed. 

(c) Anomalies of Size. The size of the placenta is subject to consider- 
able variation. A broad, thin placenta, with persistence of villi over the 
entire surface of the chorion, is termed a placenta membranacea. This 
condition is caused by hypertrophy of the entire chorion, the normal 
atrophy of the chorionic villi not occurring. Increase in size may also 
follow as the result of a dropsical condition of the membranes. The 



ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 307 

size of the placenta usually corresponds nearly to the size of the foetus, 
and varies according to the physical development of the mother. 

(d) Anomalies of Number. Of greater clinical importance than the 
anomalies of size and shape are those of number. There may occasion- 




Placenta with two accessory cotyledons, placentae succenturiatse. 
Ribemont-Dessaignes and Lepage.) 



(Modified from 



Fig. 222. 




Placenta divided into two parts 



placenta duplex. (Modified from Ribemont-Dessaignes 
and Lepage.) 



ally be found one or two distinct masses of placental tissue, produced by 
the growth of isolated patches of chorionic villi. When these accessory 
placental growths serve as a channel of communication between the vessels 



308 PATHOLOGY OF PREGNANCY. 

of tin' deoidoa and the placenta proper, they are called placenta succerUu- 
riata | Fig. 221 ). Placenta spuria- arc accessory growths whose villi have 
do direct communication with the maternal blood-stream. The impor- 
tance of these secondary growths arises from the fact that thev may 
remain unnoticed in the litems after delivery, and cause a secondary post- 
partum hemorrhage, or, becoming necrotic, may be the starting-point of 
septic processes. Cases of double placenta with a single umbilical cord 
have also been recorded. (Fig. 222.) 

Diseases of the Placenta. 

(a) Placentitis. By this term is understood an inflammation of the 
substance of the placenta. This disease is rare and its origin obscure; 
indeed, some modern pathologists contend that, by reason of the ana- 
tomical structure of this organ, a true inflammation cannot occur. How- 
ever that may be, the placenta is sometimes found indurated, thickened, 
and attached by strong adhesions to the uterine wall, the so-called 
" adherent placenta." Scattered through the substance of the placenta 
are small areas lighter in color than the surrounding tissue, caused by 
apoplectic infarcts. 

(6) Calcareous Degeneration of the Placenta is characterized by deposit 
of lime salts at the edges or within the substance of the cotyledons, in 
the shape of fine sand-like particles, or of needles or scales. They consist 
of amorphous phosphates and carbonates of lime and magnesia. No 
special pathological significance is to be attached to their presence. 
Frequently they are found in considerable numbers in placentae other- 
wise perfectly normal. 

(c) White Infarctions. These are grayish- white or yellowish-red masses 
of degenerated placental tissue which are found in almost every placenta. 
They vary in size from 1 to 5 cm. in diameter, are of a more or less 
dense structure, and are most commonly found on the maternal surface 
of the placenta. When small and few in number they are of no patho- 
logical importance. Extensive placental infarctions may be the cause 
of foetal death. Infarctions at the margin of the placenta may interfere 
with the nutrition of adjacent portions of the membranes, rendering 
them friable. Fragments of the membranes are then more liable to be 
torn off at labor and left in the uterus. 

(d) Fatty Degeneration. Fatty degeneration of the placenta occurs as 
the result of some obstruction to the blood-supply of the part affected. 
It is quite commonly observed in small areas, close to the margin of 
the placenta, and, when limited in extent, no serious results occur. If, 
on the other hand, the degeneration is extensive, the functions of the 
placenta may be so far crippled as to cause the death of the foetus. The 
terms " fibrous," " scirrhous," and " cartilaginous" degeneration were 
formerly employed as denoting an earlier stage of fatty degeneration. 
The causes of this condition are unknown. Diagnosis before the expul- 
sion of the placenta is impossible. 

(e) Placental Apoplexy. During the latter half of gestation the pla- 
centa usually becomes the seat of extravasations of blood. They are 
not diffused over large areas, but are confined to the lobes in which 
the ruptured vessels are situated. There are usually ten or twelve of 



ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 309 

these blood-clots, which vary in size from a millet-seed to that of a 
pigeon's egg, scattered at irregular intervals through the substance of 
the placenta. Some of the coagula open, through small and irregular 
orifices, upon the uterine surface of the placenta. Owing to the spongy 
character of the normal placenta, its structure is affected but for a short 
distance beyond the boundaries of the extravasation. The coagula begin 
to lose their color at the circumference, so that at a certain period the 
cavities containing the clots show a delicate whitish coating, which is 
more easily detached from the clots than from the placental tissue. Soon 
a change occurs in the clots and they become separated into two portions, 
the lighter liquid portion rising to the surface and the more solid portion 
gravitating to dependent parts. The serum undergoes absorption, while 
the solid portion, forming a clot, contracts, and becomes gradually denser 
and lighter in color. These whitish homogeneous masses were formerly 
called " concrete pus" or " tubercular matter." 

Lehmann presented at the Berlin Medical Society, in 1894, a placenta 
in which there were areas of tubercular inflammation containing tubercle 
bacilli in abundance. The placenta came from a woman who was suffer- 
ing from chronic pulmonary tuberculosis, and whose child had died ten 
days after birth, but with no evidences of tubercular infection. 

The results of placental apoplexy vary with the stage of gestation at 
which the hemorrhage occurs, with the number of clots formed, and the 
extent of placental tissue involved. The prognosis in general is good 
for both the mother and the foetus, abortion or premature labor rarely 
ensuing. When the infarcts are few and small, the pregnancy is not 
usually interrupted. On the other hand, if the effusion is large, the 
child, even if born alive, will be feeble and puny. When the hemor- 
rhages recur at short intervals the foetal heart-sounds become gradually 
weaker and finally cease. It is well to remember that women may mis- 
carry from this cause in several successive pregnancies. In all cases of 
stillbirth the placenta should be carefully examined for traces of recent 
or old apoplectic clots. 

Symptoms and Course. Slight hemorrhages are attended with no 
appreciable symptoms. Large and numerous extravasations give rise to 
pelvic pain and tenesmus, and generally result in the death of the embryo 
or foetus. The ovum may then be expelled, or may be retained as a 
uterine mole. The retention of the blighted ovum is spoken of as a 
missed abortion. 

We may suspect placental apoplexy in a patient who gives a previous 
history of the trouble and in whom the foetal heart-sounds and foetal 
movements are progressively weakening. A positive diagnosis is impos- 
sible until the placenta is expelled. 

Treatment. The treatment is the same as for uterine hemorrhage in 
general, namely, absolute rest, with the administration of sedatives for 
the milder cases, and evacuation of the uterus for those in which the 
hemorrhage is profuse. The uterus should promptly be emptied on 
evidence of the death of the ovum. 

(/) Tumors. Both cystic and solid tumors of the placenta are very 
rarely met with. A rapidly growing solid tumor, either benign or malig- 
nant, may through pressure-atrophy cause a premature expulsion of the 
foetus, with retention of the placenta for months or years. The existence 



310 PATHOLOGY OF PREGNANCY. 

of placental tumors is impossible of diagnosis before delivery, and lias 
little practical interest for the obstetrician. 

(//) Syphilis. For much of the knowledge of placental syphilis we 
are indebted to the researches of Friinkel. According to this author, 
syphilitic legions of the placenta present the following characters: 

1. When the disease has been transmitted from the father tin; prin- 
cipal lesion is hypertrophy of the villi. 

'2. When the mother is infected with syphilis, the placenta is degen- 
erated and the foetus is diseased. The vilii being filled with fatty gran- 
ules, the vessels are obliterated and their epithelial covering is thickened 
or absent. 

3. If the mother is infected during the generative act, at the same time 
as the ovum, syphilitic foci will often develop in the maternal placenta. 

4. If the mother is syphilitic before conception, or becomes so shortly 
after, the placenta is syphilitic in about 50 per cent, of cases. 

5. If the mother is not infected until after the seventh month of ges- 
tation, both foetus and placenta wholly escape. 

6. Infection of the foetus during delivery has not been proved. 

A syphilitic placenta presents evidences of fibroid degeneration, with 
great hypertrophy of the villi; the entire organ is thickened and its 
density increased. Scattered over the surface and through its substance 
are nodules of cherry-like granulations. Its general color is paler than 
normal, while around the nodules the color is yellowish-white. 

The lesions found in the placenta developed in syphilitic women are 
characterized by endo- and periarteritis, and are quite analogous to those 
observed in a syphilitic liver. (Schwab.) 

It is needless to add that one should hesitate in pronouncing a pla- 
centa syphilitic simply from the gross appearance of the organ. 

Anomalies of the Umbilical Cord. 

The more common anomalies of the umbilical cord are: Anomalies of 
length, placental insertion, and the existence of coils and of knots, and 
of navel-cord hernia. 

(a) Length. While the average length of the cord is from forty to 
sixty centimetres, there will occasionally be found cords of one and a 
half to two metres in length, and a length of even three metres has been 
noted. On the other hand, extreme shortness of the cord is sometimes 
observed, the length not exceeding ten to twelve centimetres. 

(6) Insertion. The placental insertion of the cord is at or near the centre 
of the placenta. Occasionally it is inserted at the margin of the placenta 
— battledore placenta. Sometimes the cord terminates in the membranes, 
the umbilical vessels running between the membranes from the termina- 
tion of the cord to reach the placenta. The vessels of the cord thus 
unprotected are liable to be injured during labor, with a possible fatal 
result to the foetus. 

(c) Coils About the Neck. When the cord is of unusual length it may 
be found encircling the neck or a limb of the child. The neck and the 
upper extremities are the members most commonly involved. In extreme 
cases as many as six or eight coils may be found around the child's neck. 
In such conditions extreme tension may, in exceptional cases, result in 



ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 31 1 



the death of the foetus. Breech presentation in which the cord is around 
the child's neck is dangerous to the child if labor is delayed, since 
asphyxia may occur before the constricting band can be loosened. It 
is difficult to believe that a coil can be drawn sufficiently tight to cause 
spontaneous amputation of a foetal limb, as is sometimes taught. Before 
the cord becomes tense enough to produce necrosis of the girdled member 
the umbilical circulation would be stopped and death of the foetus would 
result. Coils are observed more frequently with male than with female 
children, and oftener in multiparse than in primiparse. Coils about the 
neck are found once in five or six labors. 

(d) Knots. When the cord is of unusual length and the amount of liquor 
amnii is excessive, the existence of one or more knots in the cord is not 
uncommon. These knots are formed by the passage of the foetus through 
loops of the cord. With the above conditions and exaggerated move- 
ments of the child, it is easy to understand how several of these knots 
could be formed. Ordinarily, when there is present an average amount 
of Wharton's jelly, the vessels are protected from injury, and no bad 
results follow. Occasionally, when a knot has persisted for a consider- 
able length of time, the gelatinous material becomes displaced, and undue 
pressure is brought to bear upon the vessels. If now the knot be drawn 
tighter, foetal death may occur from asphyxia. A case of twins is re- 
ported in which the cords were united by a hard, square knot, resulting 
fatally to both children. 

(e) Navel-cord Hernia. This is a congenital protrusion of some of the 
abdominal viscera into the sheath of the umbilical cord. It is due to 
imperfect development of the abdominal wall at the seat of the hernia, 
and is frequently associated with other developmental faults. 

The size of the tumor may be a barely perceptible protrusion, or may 
reach several inches in diameter. Any of the abdominal viscera may be 
present in the sac. Most commonly the contents are omentum and intes- 
tine. Without surgical aid death frequently results. 

Treatment. Reduction of the hernia after spontaneous separation 
of the cord and amnion has been practised with success. While the cord 
and amnion are separating, dressing with absorbent cotton, to promote 
rapid desiccation, favors the prevention of sepsis. The umbilical opening 
closes by granulation, recurrence of the protrusion being meanwhile pre- 
vented by means of a firmly supported compress. 

Laparotomy, as a rule, best fulfils the indications. The operation 
should be performed immediately after birth. A partial chloroform 
anaesthesia only is required. Cord and amnion are removed by an ellip- 
tical incision through the skin just without the cutaneous margin. Adhe- 
sions are separated and the edges of the abdominal opening brought 
together with several simple sutures of silk or silkworm-gut. Care 
should be taken to approximate the fascial edges. 



CHAPTER XIV. 

PATHOLOGY OF THE FCETUS. 

ANOMALIES. 

Undeb malformations are included all imperfect, deviating formations 

of the entire body or its parts which can be attributed to malposition in 
the uterus or deviation from normal intra-uterine development. Those 
minor deviations of development which occasion no marked change of 
form and no disturbance of function are simple anomalies. Those mal- 
formations which produce remarkable deformity of the body are monsters. 
Of these there are three great groups: 1. Monstra per defectum. 2. 
Monstra per excessum. 3. Monstra per fabricam alienam. These are 
again divided according to origin and according to outward resemblance 
into a large number of subdivisions. 

Monstra Per Defectum 

Are malformations characterized by lack of, or incomplete, development. 
1. The defect is the principal characteristic: simple anomalous formation. 

A. Absence or stunting of large sections of the body. 

1. Amorphus, Acardiacus amorphus; a formless mass covered with 

skin. 

2. Mylacephalus: Vertebrae, ribs, and pelvis present; no heart; ex- 

tremities indicated; also head, by a lump. 

3. Acephalus (Plates XIII. and XIV.) : Abdominal portion of 

body, with one or two extremities, and various-sized portions of 
vertebrae; occasionally with upper extremities, and a rudimen- 
tary head. When present, the thorax is open anteriorly; the 
heart is always absent. Other internal organs are present or 
absent. 

4. Acormus, bodyless (Figs. 223, 224, 225). Head with imper- 

fect brain. Cord inserted in vicinity of throat. 

B. Absence or stunting of separate parts. 
«. Head. 

1. Acrania (Plates XV. XVI., and XVII.) : Defective vertex, 

usually associated with anencephalus; defective brain, and 
partial defect of the skin. The base of the skull is greatly 
shortened. Originates through superficial synechia of foetal 
head and amnion, or as a result of foetal hydrencephalocele. 
Acrania is also occasionally associated with pseudoencepha- 
locele. 

2. Hemicrania : Frontal, occipital, and parietal bones rudimen- 

tary. Brain rudimentary or absent: in the latter case usually 
associated with pseudoencephalocele. 

3. Microcephalia: Brain small in consequence of premature ossi- 

fication of skull bones. 
(312) 



PATHOLOGY OF THE FCETUS. 



313 



4. Cretinismus : Too short skull base, from premature ossification 
of the synchondrosis sphenobasilaris. 



Fig. 223. 




Acardiacus acormus. (Barkow.) 

bs. Rudiment of the left upper extremity, tr. Rudiment of intestine, a, a, a. Arteries, v. Vein. 

v.u. Umbilical vein, v.o.m. Omphalo-mesenteric vein. ur. Urachus. 



Fig. 224. 



Fig. 225. 





Acardiaci acormi. (Ahlfeld's Atlas. 



5. Cyclopia (Plates XVIII. and XIX.) : Both orbital fossae are 
apposed or confluent, or there is one eye which lies in one 
fossa in the median line. In the higher grades the ethmoid, 
nasal septum, and vomer are absent. The optic chiasm and 



314 



PATHOLOGY OF PREGNANCY. 



tract persist or are absent. In the brain single parts, as 

convolutions, thalamus, or olfactory nerve, are wanting, or 
it terminates anteriorly as a simple bladder. 



PlO. 226. 




Hemimelus. (Hirst and Piersol.) 



6. Agnathia : Anomaly of under jaw, or absence of the lower 
jaw processes of primary blastoderm. Usually the upper jaw, 
palate, and sphenoid bones are stunted ; the ears approach 
each other, touching at their under surfaces. 



PATHOLOGY OF THE FGETUS. 



315 



7. Aprosopus : Malformation of larger or smaller portions of the 

face — e. g., nose, mouth, eyelids. 
Vertebral column, cord, chest. 



Fig. 227. 




Skeleton of a phoeomelus. (Musee Dupuytren.) 



316 



PATHOLOGY OF PBEONANOT. 



1. Amyelie: General or partial defect of the spinal cord; origi- 

nate^ from hydromyelocele. 

2. Absence of several ribs and vertebrae. 

Pelvis and extremities. 

1. Amelns : Absence of all the extremities. 

2. Peromelus: Malformation of all extremities. 

o. PhocomelllS (Plate XX. and Fig. 227): Hands and feet rest 
on the shoulders and hips. 

4. Micromelus: Abnormally small limbs. 

5. Abrachius: Absence of arms. 

(3. Perobraehius: Defective hands and forearms on normal arms. 

7. Microbrachius: one or both arms too small. 

8. Monobrachius: Absence of one upper extremity. 

9. Sympus (Figs. 228 and 229), Syren formation: Fusion of 

lower extremities; pelvis and sacrum wanting; atresia of 
urethra and rectum. 



Fig. 228. 



Fig. 229. 





Uromelus. (Sympus monopus. FGrster.) 



Sirenomelus. (Sympus apus. FOrster.) 



10. Apus (Fig. 230): Lower extremities absent. 

11. Monopus (Fig. 231): One lower extremity absent. The cor- 
responding half of pelvis also absent (prolapse of intestine). 

12. Peropus: Stunted formation of one or both lower extremities. 

13. Micropus: Lower extremities small. 

Internal organs, intestines : The absence of entire organs is com- 
mon with malformations of head, and without a heart. It 
may occur without these anomalies. 

Absence of nose in cyclopia. 

Absence of lungs, with absence of diaphragm, and foetal hydro- 
thorax. 

Absence of lips: Acheilia. 

Absence of tongue: Aglossia, usually with agnathia. 






PATHOLOGY OF THE FCETUS. 



317 



Fig. 230. 



Fig. 231. 





Apus. 



Monopus. 



Absence of gall-bladder; the ductus hepaticus is abnormally 
wide. 

Absence of one kidney; synchronous compensatory hypertrophy 
of the other. 

Absence of urethra, with cloaca formation. 

Absence of urinary bladder; ureters open directly into urethra. 

Absence of one or both ovaries. 

Absence of uterus. 

Absence of one or both tubes. 

Absence of external female genitals. 

Absence of vulva alone. 

Absence of hymen alone. 

Absence of one or both mammary glands, commonly with syn- 
chronous absence of ribs. 

Absence of nipples. 

Absence of prepuce. 

Absence of penis. 

Absence of one or both testicles. 

Absence of seminal vesicles. 

Absence of pericardium, with ectopia cordis. 

Partial defect is found in the brain; e. g. y absence of corpus 
striatum. 

Absence of septum narium. 

Absence of inferior turbinated. 

Absence of epiglottis. 

Absence of superior segment of oesophagus, and blind ending 
of pharynx. 

Absence, partial, of trachea, with communication with oesoph- 
agus. 

Absence of tracheal cartilages, generally with abnormal fusion. 

Absence, partial, of one lung, with compensatory hypertrophy 
of the other. 

Absence of frsenum linguae, with fusion of tongue with floor 
of mouth. The fraenum may be simply too short. 



318 PATHOLOGY 01 PBEQNANOY. 

Absence of middle segment of oesophagus with sac-like dila- 
tation of the superior endj oommonly communication with 
trachea. 

Absence of colon and rectum. 

Absence, partial, of urethra, in epispadias, hypospadias. 

Absence, partial, of hymen; hymen is cribriform, fimbriated, 
or abnormally wide. 

Absence, partial, of spermatic cord. 

Absence, partial, of prepuce, short framum, phimosis. 

Absence, partial, of heart. 

1. Simple muscular sac, with veins. 

2. A chamber with arteries, and auricle and primitive veins. 

3. Two auricles, one ventricle; aorta, primitive, gives off 

pulmonary veins. 

4. Two ventricles and auricles. Atresia of ostium aorticum, 

patency of septum ventriculorum and foramen ovale. 
Pulmonary artery empties into aorta. Aorta descendens 
absent. 

5. Aorta ascendens and descendens not associated ; the latter 

communicates with pulmonary artery through ductus 
Botalli. 

6. Arteria pulmonalis narrow, closed, or absent; its branches 

communicate with aorta. 

7. Both arteries abnormally narrow; heart-cavities greatly 

dilated, septum incomplete. 

8. Situs transversus of the aorta and pulmonary artery. 

9. Patency of foramen ovale, ventricular septum, and ductus 

Botalli. 
10. Anomalous formation of valves; increase or diminution 
in their number. 
C. Abnormal smallness. 

1. Dwarfs (Nansomia, Microsomia): Fully developed individuals 

under 112 cm. Generally the head and trunk are of relatively 
unequal size. Occasionally all parts are in proportion. 

2. Single parts abnormally small : Heart and bloodvessels (hypo- 

plasia in chlorotics); lungs (in diaphragmatic hernia and dys- 
tocia of abdominal organs into thorax); brain (microcephalus), 
spleen, thyroid, lips, tongue, frsenum, stomach, penis, testicles, 
toes, ears. 
II. Arrested development characterized by disturbance of the normal 
metamorphosis of an originally properly segmenting ovum : No 
defect, but metamorphosis of part or organ in normal position, 
with derangement of its component parts. 

1. Formation of two or three renal pelves, through unusual arrange- 

ment of the separate renculi of the kidney; also lateral dispo- 
sition of the pelves. 

2. Fusion of all the renculi, to form one kidney: Horseshoe kidney. 

The fusion is usually on the inferior pole, and occasionally asso- 
ciated with dystocia in the pelvic cavity. 

3. Communication between trachea and oesophagus. 

4. Communication between rectum and vagina (cloaca formation). 



m 



PATHOLOGY OF THE FiETUS. 



319 



5. Hermaphroditismus. (Fig. 232.) There are two varieties — 
true and false. In the former, male and female generative 
organs are present; in the latter, there are a male or female 
generative canal and either male or female genitalia. Of the 
true variety there are three forms : 



Fig. 232. 




Hermaphroditismus bilateralis. (Heppnek.) 
a. Glans penis. 6. Corp. cavernosa penis, c. Corp. cavernosa of urogenital canal, d. Its bulb. 
e. Its anterior arm. /. Membranous part of urogenital canal, h. Prostate, i. Bladder, k. Ureters. 
I. Vagina, m. Uterus, n'. Fundus uteri, o, o. Tubes, p, p. Their infundibula. q, q. Ovaries. q',q'. 
Ligaments of ovary, r. Eight testicle, s. Left testicle, t. Left parovarium, u. Right parovarium. 
v. Hydatid of Morgagni. n, w. Bloodvessels, x, x. Round ligaments, y, y. Broad ligaments. 
*. Muscle fibres from bladder and vagina. 



1. Bilateral : Ovaries and testicles on both sides. 

2. On one side, an ovary; on the other, a testicle. 

3. Unilateral : On one side, testicles; on the other, ovaries. 

Of the pseudohermaphroditism (Fig. 233), two forms — i. e., male 
and female : 
1. Male pseudohermaphroditism (with testes) falls into three 
subdivisions : 



320 



PATHOLOGY OF PREGNANCY. 



(a) Complete : Testicles present; tubes, uterus, vagina, and 
female external parts. 

(6) Kxternus : Testes and male genital canal, with female exter- 
nal parts. 

(<-) Interim- j Persistence of Midler's duets, rudimentary 
vagina, uterus, and tubes; testes and male external parts. 

2. Feminine pseudohermaphroditismus (with ovaries) falls also 

into three subdivisions : 

(a) Complete: Ovaries, persistent Wolffian ducts; male exter- 
nal evuitals. 

(6) Externus : ( )varies, internal female genital canal, external 
male organs. 

(c) Interims: Ovaries; external female genitals; persistent 
Wolffian ducts. 



Fig. 233. 




Spurious hermaphroditism. The round bodies are testicles. (After Hirst and Piersol.) 



In hitherto observed cases of the true variety, functionally active male 
and female organs were not present; the testicles or ovaries were stunted. 
The majority of the false variety belong to the male sex. The indefi- 
nite location of the organs of generation, and the indefiniteness of all 
external appearances — voice, beard, breasts, sexual instincts. 

Arrest of development with prevention of complete ripening of 
the embryo : Persistence of a certain stage in development. 
. Duplex uterus and vagina through incomplete fusion of Muller's 
ducts, or through stunting of the same. Rarely the uterus and 
adnexa fail completely; usually a solid rudiment obtains. Uterus 
unicornis arises from absence or stunting of one Muller's duct. 
Cleavage : Most of the cavities and canals of the body are origi- 
nally plates, which bend to form rings in the first month; and by 



III. 



A 



1). 



PLATE XIII. 




Aeephalus. (Hirst and Piersol.) 



PLATE XIV. 




Aeephalus. (Hirst and Pierrol.) 



PLATE XV. 




Pseudeneephalus. (Hirst and Piersol.) 



PLATE XVI. 




Aneneephalus. (Hirst and Piersol.) 



PLATE XVII 




Aneneephalus. (Hirst and Piersol.) 



PLATE XVIII 




Cyeloeephalus. (Hirst and Piersol.) 

(Cyclops.) 



PLATE XIX. 




Skeleton of Cyeloeephalus. (Hirst and Piersol.) 









• 



^ 



PLATE XX. 



§ 



-? 




in 




'/ 



Pl-ioeomelus- 



(Hirs t and Piersol.) 



PATHOLOGY OF THE FCETUS. 321 

apposition and fusion of their edges, complete the cavities and 
canals. Hinderance of this apposition and fusion results in cleav- 
age of the part. Lips, jaws, palate, neck, trachea, intestines, 
bladder, skull, vertebra?, thorax, and abdomen may thus remain 
separated. Cloaca formation consists in arrested development, 
resulting in communication between rectum, bladder, and the 
genital canal; this arrest of development occurs from the fourth 
week of embryonic life to the middle of the third month. 

1. Cranial and vertebral cleavage : Cranioschisis, rachischisis, crani- 

orachisis are in small part due to embryo-amniotic adhesions, 
mostly to lesions of the central nervous system, which are traced 
to the meninges. CEdema of the cerebro-spinal arachnoid 
(hydromeningocele cerebralis and spinalis) or ectasia of the 
ventricles and central canal of the cord (hydrencephalocele, 
hydrocele medullae spinalis) either prevents fusion of the poste- 
rior vertebral arch or leads to resorption and perforation of the 
bones. Spina bifida is in rare cases a pure hydromeningocele 
spinalis, as a rule only in the inferior portion of the cord : 
hydromeningocele spinalis sacralis or lumbosacralis. When 
the cleavage is situated higher up there is usually a hydromy- 
elocele. This is as a rule associated with marked stunting, 
with usually complete interruption of the cord. The spinal pro- 
cesses usually fail completely in spina bifida. Occasionally an- 
terior vertebral fissure occurs with spina bifida. As a rule the 
protruding sac has in its centre a funnel-shaped deepening. This 
is the place of fusion with the inferior end of the spinal cord. 
Hydrencephaloceles, with and without cerebral atrophy, are 
located usually in the median line, most commonly complicated 
with spina bifida atlantis or cervicalis. Through pressure the 
adjacent areas of brain and cord are destroyed. When the 
sac is very vascular it forms at the base of the skull a red, 
spongy mass : fungus cerebri, pseudoencephalocele. 

2. Cleavage of lips, jaw, and palate (Plate XX). Wolfs jaws : 

chelio-guato-palato-schisis, single or double sided, through 
imperfect conjunction of upper jaw and palatal processes; the 
first with the anterior end of the frontal process to the middle 
jaw and vomer. The fissure stretches through the lip, upper 
jaw, and palate. The soft palate and uvula are cleft in the 
middle. There is open communication between nose and mouth. 
This anomaly is present in cleavage of chest and abdomen. 
The upper lip and jaw can be simply cleft — unilateral or bilat- 
eral. The cleavage can extend to the nares. In hare-lip either 
a fissure or cleavage obtains, which in the latter case can 
reach the nares. Hare-lip is oftener left-sided; but may be 
bilateral. 

3. Fistula coli congenita is a lateral or median opening, about 2. 5 

cm. above the sternoclavicular joint, on the inner border of 
the sterno-mastoid. The opening is very small, and covered 
with ciliated epithelium, and has a blind end, which is occa- 
sionally sacculated. Lateral fistula is resultant from hindered 
closure of the third and fourth embryonic plates; the median 

21 



;;l>l> PATHOLOGY OF PREGNANCY, 

fistula, from absenoeof oonjunotion of the third and fourth em- 
bryonic plates. 

4. Cleavage of chest and abdomen Lies always in the anterior median 

line of the body. Through hinderance of juncture of the vis- 

eeral plates the entire thorax and abdomen to the navel are 

deft. The thoracic and abdominal viscera are then displaced 
forward. In simple thoracic cleavage ectopia cordis is usual. 

Sternal fissure IS the least degree of thoracic cleavage. (ias- 
troschisis, or abdominal cleavage, may stretch from manubrium 

to symphysis, ensiform to the pubis or navel. In the latter 
case, separation of cord, omphalocele, or umbilical hernia of the 
cord is present. If the abdominal cleavage reaches the pubis, 
vesical cleavage is also present. 

5. Vesical cleavage : Ectopia vesicae urinaria? is characterized by 

the appearance of the posterior bladder wall through a cleft 
abdominal wall. The urethra is also occasionally cleft and 
forms an open border leading to the upper surface of the penis 
— epispadias. Usually cleft bladder is associated with imper- 
fect fusion of the symphysis, absence of clitoris and vagina, 
vaginal atresia, and stunting of penis. 

6. Intestinal cleavage : Fissura intestinalis congenita is a rare com- 

plication of abdominal cleavage. Here, as in vesical cleavage, 
an open caecum or colon ascendens appears in the abdominal 
cleft. 

7. Cloaca formation : 

1. With abdominal and vesical cleavage : Abdominal viscera 

protruded and surrounded by a sac, on the under surface 
of which is seen the cloacal orifice. The intestinal opening 
is located above in the centre of the cloaca; the colon termi- 
nates blind or is absent; the ureters open in the bladder, also 
the seminal vesicles, or, in females, the separately developed 
Miillerian ducts. 

2. With vesical cleavage : In the centre of the cleft bladder is 

the intestinal opening; on the sides, the opening of the 
ureters, and seminal vesicles, or vagina. 

3. With closed bladder: Rectum absent (atresia ani); rectum 

communicates with urinary or genital canal. 

8. Hernia peritonealis congenita : Congenital hernia? of the abdo- 

men are characterized by dystocia of the abdominal viscera. 
They originate in the bulging of a less resistant portion of the 
peritoneum, which forms a hole or fissure in the abdominal wall. 
External and internal abdominal hernia? are to be differenti- 
ated. The former are visible from without, and resultant from 
outward bulging of the abdominal wall. The latter are not 
perceptible externally. 
External abdominal hernia? are : 

H. inguinalis interna, media, externa. 

H. cruralis, ischiadica, perinealis, vaginalis, foraminis ova lis, 
umbilicalis, and abdominalis. 
Internal abdominal hernia? are : 

H. diaphragmatica, retroperitonealis, mesenterialis. 



PATHOLOGY OF THE FCETUS. 323 

The majority of these are acquired. Congenital varieties are : 
H. inguinalis externa (outward from the arteria epigastrica, fol- 
lowing the spermatic cord). 
H. umbilicalis : In the foetus a loop of ileum lies within the navel 
opening. 

C. Atresia? : Result from failure of canalization of solid areas of cells, 

destined to become hollowed out, to form sacs and tubes. 

Atresia of pylorus, intestines, ureters, urethra, Fallopian tubes, 
uterus, vagina, hymen. 

Atresia through failure of the skin to bulge toward, and open into, 
perfectly formed canals. 

Atresia oris, ani (usually associated with atresia of vagina, urethra, 
or seminal vesicles). 

Atresia through closure of orifices : Vulva, nose, ear; of the vagina 
and hymen, either total or partial absence of the former from 
obliteration of the Miillerian ducts. Occasionally there is an 
imperforate diaphragm immediately behind the hymen. 

D. Various other embryonic conditions, without corresponding exter- 

nal evidence of the anomaly : 

1 . Diverticula : Of the intestines are congenital widenings or 

bulgings of the gut; remains of the ductus omphalomesenteri- 
cus, from the time of communication of the intestines with the 
umbilical bladder (allantois). Meckel's diverticulum lies in 
the inferior segment of the ileum, on the convex side, opposite 
the mesentery, about one metre from the Bauhinian valve. It 
is occasionally connected with the navel by the obliterated 
ductus omphalo-mesentericus. 

2. Cryptorchismus : Is the foetal condition. Dystocia of one or 

both testicles, usually one, the organ remaining in the abdom- 
inal cavity. Descent of testes begins about the third month, 
these organs entering the processus vaginalis during the seventh 
month. This anomaly is usually associated with microschismus. 

3. Congenital luxations : Slipping of the head of the joint out its 

socket, from arrested development of the latter. 

4. Club-foot : Pes varus, equino- varus, flat-foot, pes valgus, planus, 

equinus, also the combinations equino- varus and equino-valgus, 
pes calcaneum, also talipes-manus — club-hand. 

In pes varus the outer edge of the foot is turned backward, the 
sole inward; in valgus the inner edge of the foot turns 
under, the sole points backward, the back forward; in calca- 
neus the heel looks backward, the sole forward. The foetal 
placing of the feet corresponds nearly with pes varus; this 
position is readily observed in the new-born. 

Persistence of a foetal condition, arrest of, or overdevelopment, 
and pressure in utero, also muscular contracture of centric 
origin, are causes of these anomalies. Talipo-manus is occa- 
sioned by rudimentary development of the radius. 



324 P ' THOLOQ )' OF PREGNANCY, 

Monstra Per Excessum. 

Malformations characterized by over-large, over-heavy, and super- 
numerary development. 

I. Over-large development : 

1. Giants, macrosomia: Apparent before birth, or commencing im- 
mediately after. Affects in the main the bony skeleton and 
muscular system. Sexual function is very often suppressed. 
'2. Abnormally large single parts : 

Acromegalic (Marie) : Enlargement of the pointed parts of the 
human body, hands, feet, nose, lips, chin, tongue, later the 
lower extremity; the distal portion of the forearm, lower jaw. 
The hypertrophy begins in youth or middle life, affects the 
bones and soft parts, and is always associated with muscular 
weakness, sensory disturbances, cephalalgia, and loss of mem- 
ory, also dimness of vision and anaemia. According to Fried- 
reich and Erb, this lesion is seen in several members of the 
same family. 
Macrocephalus; hydrocephalus (apparent cerebral hypertrophy, 
actual atrophy); macroglossia ; microdactylia; dermatocele 
adnata (sac-like, fold-forming hyperplasia of skin); excessive 
size of thyroid, thymus (asthma thymicum), of the ovaries, 
omentum, mesentery (occasions sometimes twisting and incar- 
ceration), of the intestines, ureters, clitoris, penis, uvula. 
3. Abnormal development of hair, and pigment (hirsutio adnata, 
hypertrichiasis). 

II. Supernumerary formation : 

A. Monstra duplicia, twin formation; general or partial duplication 
of the body. Either both twins are equally developed, or one is 
stunted and is parasitic to the other, more or less normally de- 
veloped autosite, from which it is nourished. 

a. Duplication of upper portion of body : Terata anadidyma. 

1. Diprosopus : Double face, one body, two fused, incomplete heads 

(brain absent). 

2. Dicephalus : Double head; one body, two heads. 

3. Ischiopagus : Two upper bodies, a common pelvis, two or four 

lower extremities. (Fig. 234.) 

4. Pyopagus : Two nearly separate bodies; sacrum, coccyx, rectum, 

and occasionally the vagina single. 
/9. Duplication of lower portion of body: Terata catadidyma. 

1. Dipygus : Double body, one head. 

2. Syncephalus (Janiceps) : Two individuals fused together by head 

and hips. 

3. Craniopagus : Two bodies fused on heads, and often shoulders. 
y. Duplication of upper and lower ends of bodies : Terata anacata- 

didyma. 

1. Prosopothoracopagus: Skull cavities separated, under jaws de- 

veloped, breast and neck fused. 

2. Thoracopagus : Fusion of thoraces of two otherwise fully sepa- 

rate individuals (Siamese twins). 



PATHOLOGY OF THE F(ET US. 



325 



3. Epignathus : Prosopothoracopagus parasiticus: Foetus in fcetu. 

The parasite is associated with the mouth of the autosite, 
usually the hard palate, and projects from the mouth. 

4. Epigastrius : Thoracopus parasiticus : Foetus in foetu. Parasite 

attached from ensiform to navel of autosite. 

5. Engastrius Abdominal inclusion of the parasite. 

6. Rachipagus : Connection of two individuals at only one point on 

the vertebral columns; head, neck, a part of thorax, and lower 
extremities duplicated. 

Fig. 234. 




Ischiopagus tetrapus. 
Mother, a full-blooded Indian, delivered by Dr. Felipe Martinez, San Francisco, Cal. 

B. Monstra triplicia: Triple monsters; are exceedingly rare. 

C. Supernumerary extremities : 

1. Polymelia: The number of entire or half extremities is increased. 

2. Poly dacty lie : The number of fingers or toes is increased. 

D. Supernumerary organs. Practically all the separate organs may 

be increased in number. 



Monstra Per Fabricam Alienam. 

Anomalous position of parts or organs : 

1. Situs trans versus, inversio viscerum. Rare. Consists in com- 

plete transposition of otherwise healthy organs. 

2. Dystopiae of separate organs. 

Heart : Dextrocardia, ectopia cordis, in thoracic fissure. 
Bladder: Ectopia vesicae urinaria? in fissura abdominalis. 



326 PATHOLOGY OF PREGNANCY. 

Spleen ^ 

Stomach | In hernia diaphra<;inatica congenita, and fissura ab- 

Liver ( dominalis. 

[nteetines j 

Ovaries: In inguinal region, or labia majora; anomalous descent. 

Left kidney: In or on edge of pelvic cavity, or in the fovea 

inguinalis. 
( laput coli on left side. 

Colon dcscendens, median through radix mesenterii. 
Great hepatic lobe on the left. 






CHAPTER XV. 

PATHOLOGY OF THE FCETUS.— Continued. 
DISEASES OF THE FCETUS. 

Pathological conditions of the foetus are classified as follows : 
Hereditary disease ; 
Developmental errors ; 
Acquired disease; 

Nutritional errors; 

Parasitismus; 
Trauma from 

1. Local pressure effects; 

2. External violence. 

Heredity. Recent advances in cytology have done much to throw light 
upon the subject of inheritance of disease, especially in the cytology and 
the modus operandi of the fertilization of the ovum. The classical 
researches of Flemming, van Beneden, Bovari, and O. and K. Hertwig 
have proven for all time that fertilization of the ovum consists essen- 
tially in the fusion of an exact quantity of nuclein or chromatin from the 
spermatozoid, with a similar quantity of the same substance in the ovum. 
The resulting segmentation of the ovum must produce cells whose con- 
stituent elements are a combination of chemical — vital — materials from 
both male and female progenitors. This mechanical theory abundantly 
explains the remarkable reproduction in the offspring of striking char- 
acteristics of either or both parents. 

In the light of present knowledge it is impossible to formulate accu- 
rately the ultimate changes of a pathological nature occurring in those 
morphologic elements whose union is to produce a new entity; it can 
merely be assumed that they are essentially chemical — vital. 

It must be that if the reproductive elements of either or both parents 
be impaired or altered in their nature, the change will inhere in the 
foetus, and will be more or less evident, depending upon the condition of 
the other parent and his or her power to offset the deficiency. This 
theory of heredity holds equally for disease as for personal characteris- 
tics. The question thus arises, can such diseases as tuberculosis and 
syphilis be properly hereditary? Assuming both to be of parasitic 
origin, they canuot, in view of what has just been stated. Any heredity 
in these diseases must consist in regressive changes in the reproductive 
elements of one or both individuals, whereby the offspring is deprived 
of the power to resist invasion of the parasite, and offers a suitable 
soil for its propagation. The frequent skipping of a generation in tuber- 
cular families supports this view, as it goes to show that in the union 
of a tuberculously inclined individual with a perfectly healthy one, 
the peculiar lack in the reproductive elements of the one is counter- 
balanced by the normal elements in the other, to the extent of producing 
immunity in the immediate offspring. 

(327) 



PATHOLOGY OF PREGNANCY. 

In general, it may In-said that heredity in disease consists in alteration 
of quality, quantity, or both, of the original elements of fertilization ; 
which alteration persists in the fertilized ovum, and tends to limit its 
normal development, and inaugurates pathological processes in the foetus. 

It cannot at present, however, l>e denied that these changes may be char- 
acteristic of certain diseases, Buch as tuberculosis, syphilis, and alcoholism. 

Foetal Infection. It is proved that the foetus in utero may suffer infec- 
tion. The infection may originate from the mother, father, or both, and 
may be Bimple or mixed. Its origin may also be external, in the Bense 
that the secretions of the genito-urinary canal of an otherwise healthy 
mother may become contaminated with septic organisms from douche 
tubes, etc., which invade the foetus through the liquor amnii (Menge and 
Kroiii- i. 

Foetid infection is acute or chronic. Of the acute processes, scarlatina, 
measles, smallpox, recurrent fever, and erysipelas are recorded, together 
with septic and pyemic infections, where pathogenic organisms were 
recovered from the organs and tissues of the foetus. Death and expul- 
sion of the foetus are usual in these cases. 

Of the chronic infectious processes tuberculosis and syphilis are the 
chief. Malarial lesions of organs have been described without discovery 
of the plasmodium. Foetal infection occurs through the utero-placental 
tissues, the cord, and the liquor amnii. Normally the latter has strong 
germicidal properties, which may, however, be destroyed. 

Any area of the foetal body may become infected. The determining 
factors are : the primary source of the infection, the resistance of differ- 
ent tissues, the nature of the infecting organism. The organic lesions 
will correspond with the pathogenesis of the infecting germ. Erysipelas, 
multiple abscess, and gonorrhoeal ophthalmia are examples of acute para- 
sitic infections. Tuberculosis and probably syphilis are examples of 
chronic infection. 

Inflammation. Acute inflammatory processes are infectious in their 
nature. They are important from their tendency (1) to destroy impor- 
tant structures, as the eye in gonorrhoea; (2) to limit development, as in 
hare-lip consequent upon inflammatory adhesion of the amnion to the 
foetal face; (3) to produce death of the foetus, as in erysipelas. Of the 
chronic inflammatory processes tuberculosis and syphilis are most prom- 
inent and best understood. Congenital hydrocephalus is a consequence 
of chronic meningeal inflammation. 

Hemorrhage. Prenatal haemophilia is recorded. Aside from the hemo- 
philic diathesis, hemorrhage will result from the septic condition and 
trauma. 

In sepsis the hemorrhages are usually petechial, and may be widely 
distributed. Very valuable evidence of the existence of sepsis lies in 
the finding of numerous very small petechia? in the subserous tissues. 
Small hemorrhages may also be caused by cardio-vascular disease or 
anomaly. 

Traumatism will produce large hemorrhages into the cavities of the 
brain, thorax, and abdomen. 

Cephalhematoma results from pressure effects. 

A. Jacobi asserts that small cerebral hemorrhages may occur in the 
foetus, which, primarily unnoticed, produce ultimately epilepsy. 



DISEASES OF THE FCETUS. 329 

i 

The writer has autopsied several cases of fatal cerebral hemorrhage in 
stillbirths, or deaths a few hours post partum, occurring in Dr. Jewett's 
service at the Long Island College Hospital, which originated from a 
cardiac anomaly described below. 

Malnutrition. This condition in the foetus may be due to heredity 
{vide supra), or to disease of the utero-placental tissues or the cord. It 
may result from an abnormally large quantity of amniotic fluid or the 
reverse of this, also from imperfect development of an organic system, 
as, e. g., microcephalus, or general vascular hypoplasia. 

Specific diseases, particularly tuberculosis and syphilis, will cause pro- 
found foetal malnutrition, resulting often in death. In marked cases the 
foetus presents the general appearances of atrophy, the face looks old, 
and the skin is loose. 

Foetal Death occurs during any period of gestation. Very soon after 
conception it will be followed by total absorption of the products. Later 
it will give rise to mole. In the later months of pregnancy the dead 
foetus will undergo maceration, putrefaction — which may involve the 
mother in sepsis — mummification, or calcification. The dead foetus may 
be retained in the uterus for years. Dr. Lusk reported a case in which 
a normal labor was followed fourteen years later by the removal of a 
calcified foetus. 

Foetal death is caused by hereditary disease, acute infectious diseases, 
foetal tuberculosis, syphilis, and malnutrition. It is also caused by 
utero-placental disease, and by twisting and knotting of the cord, by 
hyper- and oligohydramnios, and by trauma. 

Diagnosis of Death of the Foetus. The diagnosis is difficult in the early 
months of gestation. The intra-uterine temperature of the mother is 
always higher than the vaginal while the foetus is alive. An equal or 
lower temperature in a uterus containing the product of conception is 
probable evidence of foetal death. On bimanual examination the uterus 
presents a boggy feel. Pelvic tenesmus is usually present in some degree. 

The death of the foetus can, as a rule, easily be determined when it has 
occurred after the period when foetal movements are perceptible. The 
most reliable signs are the persistent absence of foetal heart-sounds and 
of foetal movements. The abdomen ceases to enlarge; the breasts become 
flaccid and diminish in size. 

A fetid discharge from the vagina containing exfoliated epidermis is 
a certain indication of the presence of a dead foetus. Should the foetal 
head present at the pelvic inlet the cranium is found to be soft, and the 
cranial bones loose and movable, overlapping one another. The lips of 
the dead foetus in a face presentation are flabby and motionless. No 
caput succedaneum can form during delivery, as there is no foetal circula- 
tion to make it possible. Large quantities of meconium may be dis- 
charged, though the breech does not present. Yet this frequently occurs 
during the birth of a living child. Should the breech present, the exam- 
ining finger will discover that the anal sphincter does not contract. 
Should the umbilical cord prolapse, it will be found flaccid and pulseless. 

Infection of the mother from the dead foetus in utero is extremely apt 
to occur, and its presence is indicated by depression, furred tongue, chilli- 
ness, fever, a pale and sallow color. 

Errors of Development. Minor malformations, as hare-lip, supernu- 



330 PATHOLOGY OF PREGNANCY. 

merary fingers, etc., are Anomalies; major malformations, as anenoeph- 
alus, involving a considerable portion of the foetus, are Monstrosities. 
I'j) to the time of Lemerey, Winslow, and A. v. Sailer, monsters were 
regarded as wonders of evil omen. 

Winslow and llallcr regarded developmental errors as primary anom- 
alies of the seed, present in it before fertilization; while Lemerey regarded 
them as due to interference with the processes of embryonic development. 

A- embryology became better known, J. F. Merckel and Geofrroy- 
Saint-Hilaire, father and son, treated the whole subject of teratology more 
thoroughly, and called attention to the relationship between arrest of 
normal development and persistence of the foetus in a certain stage of 
development. 

Forster was the first to collect and classify the literature on this sub- 
ject; and, following him, Ahlfeld rearranged and extended it in a series 
of plates. (Thonia.) 

Many interesting experiments have been made by such investigators 
as Geoffroy-Saint-Hilaire, Panum, Dareste, L. Gerlach, the brothers 
Hertwig, lloux, and others, with the result of proving that anomalies in 
embryonic development may be induced by mechanical means, such as 
separation of the elements of the segmenting ovum and axial change of 
its position during segmentation. These facts show the influence of 
environment upon foetal development. Thonia, of Dorpat, draws atten- 
tion to the fact that twins occurring from a single ovum develop circu- 
latory disturbances in the nature of venous obstruction, with hepatic and 
other organic congestions due to anastomosis of the vascular systems of 
both individuals. Others have produced twins in the ova of rana by 
permanently inverting the primitive streak. 

Notwithstanding all the brilliant work in this direction, we still know 
but little regarding the etiology of anomalous development. It is pretty 
clear that heredity, malposition of the blastoderm, intoxications and 
infections of the foetus in utero, all play a part in the arrest of develop- 
ment, as well as oligohydramnios and trauma. 

As Thoma well puts it, foetal disease per se is also significant in the 
production of anomalies : as increase of amniotic fluid, oedema of the 
embryonic tissues, organized adhesions between the foetal tissues, and 
between these tissues and the amnion, and even isolation of areas of 
embryonic tissue, e. g., dermoid cyst. 

The same author also justly remarks that aside from gross errors in 
development, giving rise to extensive deformity, it is very important to 
remember that anomalies may obtain in single organs, which in time will 
produce secondary disease. Many aplasia? will make life impossible to 
the child after birth; others will handicap it, and still others will con- 
stantly menace its existence. Practically those anomalies which tend to 
limit the possibilities of the child after birth are of greater importance 
to it; while monstrosities are of greater importance to the mother in the 
often grave complications they occasion during parturition. 

Systematic Organic Lesions. There is not space in an article like this 
for a detailed description of all the lesions of the foetal organs. In 
general, it may be said that the fundamental principles underlying these 
lesions are identical with those governing lesions in the adult, the one 
difference being rather of result — i. e., arrest or alteration of develop- 



DISEASES OF THE FCETUS. 331 

ment in many instances in the foetus. In describing some of the more 
important organic diseases, only such minor anomalies will be considered 
as tend to induce other pathological conditions. 

Heart. Endocarditis is almost always in the right heart; is rarely 
acute, usually chronic, and due to syphilis. 

Myocarditis is acute (from infection, Menge and Kronig), or chronic, 
and due to syphilis. In the latter case it is interstitial. 

Endocarditis, with anomalous or incompetent valves may produce a 
vicious circulation, and chronic venous hyperemia; cases are reported in 
which typical nutmeg-liver and renal cyanosis complicated this lesion. 
Hemorrhage, marked or slight, may also be caused by it, and may in- 
volve any organ, notably the brain and lungs. Through the courtesy 
of Dr. Jewett, the writer has been able to autopsy several stillbirths 
and infants dying a few hours after birth in the maternity wards of the 
Long Island College Hospital, in which it was revealed that the pul- 
monary artery was immediately confluent with the thoracic aorta 
(through a large and persistent ductus arteriosus ?), with extremely small 
branches running to the lungs. The right ventricle was hypertrophic. 
Aside from a few petechia in the subserous tissues generally, all of the 
cases showed very considerable hemorrhage at the base of the brain and 
around the medulla and pons. In ail the parturition was normal, with 
not the slightest evidence of sepsis. In some of the cases there was 
pulmonary hemorrhagic infarct. In these cases, if the ductus arteriosus 
be regarded as the source of confluence between the pulmonary artery 
and the thoracic aorta, its structure was unusually thick, and in every 
way similar to the other portions of the vascular channel at this point. 
The writer believes that this may be a more common condition than is 
generally supposed. 

According to Orth, who recites a very remarkable instance, hypoplasia 
cordis, with general vascular hypoplasia, is a very important foetal con- 
dition, bearing direct relation to chlorosis in the young. His patient, a 
girl in her teens, died with marked chlorosis, and the autopsy revealed an 
infantile heart with an aorta that scarcely admitted an ordinary lead- 
pencil within it. It is probable that this condition may cause foetal 
malnutrition not infrequently. 

Tachycardia and arrhythmia are caused by nervous anomaly, general 
cardiac insufficiency, systemic foetal infection, uterine pressure, and foetal 
debility. 

Tuberculosis is rare, and always discrete. 

Bloodvessels. Anomalies of the vascular distribution are directly re- 
sponsible for lack in development of entire parts, as, e. g., sl cerebral 
hemisphere. 

Hemorrhage is by rhexis from cardiac lesion, or trauma, pressure in 
utero, efforts to respire before or during parturitiou, and haemophilia, 
and by diapedesis in sepsis, icterus neonatorum, and probably haemophilia. 
The hemorrhage of sepsis is very important, as it affords a point in diag- 
nosis of the condition. The hemorrhage is always multiple and petechial, 
or at least small, and most conspicuous in the subcutaneous and subserous 
tissues. 

Vasculitis. Acute vascular inflammation may supervene in the foetal 
bloodvessels, and involve the adventitia or intima, or be diffuse ; but the 



332 PATHOLOQ V OF PREGNANCY. 

most important inflammatory changes arc chronic, and due to svj)liilis. 
Bere there is active, small round-cell infiltration, with hyperplasia of 
connective tissue. lather the outer or inner, or both, coats are involved; 
and the lnmina of the vessels may be diminished and eccentric. It can- 
not be doubted that Buch chronic vascular inflammations may arrest 
development, and, by inhibiting osmosis, produce profound nutrition 
disturbances. 

Finally, microscopic examination of the tissues of foetuses suspected 
to have died of infection lias yielded positive results to a number of 
investigators. The writer, through the courtesy of Dr. Jewett, observed 
a multiple hepatic infection in an infant dying shortly after birth, where 
microtome sections revealed numerous foci of small round-cell infiltra- 
tions, and, amongst these cells and in the intralobular capillaries, micro- 
cocci. Menge and Kronig record a case in which septic anaerobes were 
found in the right heart of a stillbirth, where the liquor amnii had 
become infected. 

Hyperplasia and aueurisms of the arterioles, capillaries, and venules 
are common, aud form verrucose naevi and so-called birth marks. 

Lymphatics. These structures are the seat of inflammation and are 
associated with the lesions of elephantiasis foeti. They are often angi- 
omatous, and are common carriers of micro-organisms. 

Lungs. Pulmonary oedema and hemorrhage occur as results of cere- 
bral and cardio-vascular lesions, pressure effects in parturition, trauma, 
and sepsis. Hemothorax from trauma is recorded. Atelectasis is normal 
until birth; it persists after birth from prenatal centric lesions and defects, 
or obstruction of the respiratory tract with inhaled mucus. It is partial 
or total. 

Disseminated pneumonia is frequent in foetal infection. 

Syphilis gives rise to " white pneumonia" (Osier) and interstitial and 
vascular hyperplasia. 

The writer has seen undoubted septic pneumonia in several cases of 
stillbirth in puerperal sepsis. Cross section of these lungs revealed 
characteristic areas of infiltration, which microscopic examination proved 
to be foci of small round cells, whose centres were in coagulation necrosis. 
Pleuritis has been recorded. 

Spleen. Aside from anomalies, this organ will show the characteristic 
changes of sepsis, and, it is claimed, of malaria. 

Primce Vice. Acute inflammatory lesions may obtain from infection. 
Menge and Kronig find evidence of it in cases where infection from the 
amniotic fluid apparently started in the stomach and intestines. Tuber- 
culosis and syphilis occur in the stomach and intestines, and the mesen- 
teric and retroperitoneal glands. 

Of the anomalies, one or two are liable to produce trouble later in life. 
The writer has autopsied three cases of fatal perforative appendicitis 
where situs transversus was found. The caput coli in one case was 
literally transposed; in the other two it was displaced, and closely 
adherent to the sigmoid flexure. Diverticula are seen in any part of 
the canal, and may be sufficiently large to produce serious trouble. The 
stomach may be nearly inverted, and the cardia brought lower than the 
pylorus; or it may assume a vertical position. Gastric hypoplasia may 
be marked. 



DISEASES OF THE FCETUS. 333 

Atresia ani and recti may be of sufficient degree to prove fatal, or may 
be amenable to operation. 

Liver. Reveals characteristic structural changes incident to cardio- 
vascular lesions and the parenchymatous changes of septic infection. 
It may be the primary focus of infection in the foetus, the source of 
which is the cord or the liquor amnii. (Menge and Kronig.) 

Icterus neonatorum will result from such infections, and may be com- 
plicated with fatal hemorrhage. 

The writer has seen, and Menge and Kronig report, cases in which 
microtome sections revealed foci of small round cells, micrococci in the 
writer's case, and a short bacillus in those of Menge and Kronig. 

Kidneys. Aside from their interest merely as curiosities, the renal 
anomalies are very important from their relative frequency and the bear- 
ing they have on surgery. A single kidney may be developed, or the 
two may fuse to form a horseshoe, or both may locate in the pelvis. 
One or both organs may be destroyed by hydronephrosis due to atresia 
of the genito-urinary canal at some point. 

All of the changes due to renal cyanosis may be present as results of 
cardio- vascular lesions. These organs also show the general changes of 
infection; and localized areas of infection have been found, especially in 
the Malpighian pyramids (Menge and Kronig). 

A very important congenital condition of the kidney, described by 
Orth, Rosenstein, and others, is multiple cystic degeneration of the cor- 
tical tubules. According to Rosenstein the crypts may be so numerous 
as to leave but little functionating tissue. The cysts never attain a 
large size. The condition is often accompanied with renal hemorrhage, 
and is, unfortunately, usually bilateral. The writer has seen one such 
case which came to operation for renal hemorrhage and tumor. The 
right kidney was very large, weighing about three pounds, and studded 
with hundreds of cysts, which varied in size from a pullet's egg to that 
of a pin-head. In this case both organs were involved, and the patient 
died of uraemia. The etiology of these cystic kidneys is very obscure. 
Not infrequently an infant dies within a few days after birth, and the 
kidneys are found to contain uric-acid infarcts, which are located, as a 
rule, in the medullary portions of the collecting tubules. According to 
Ziegler these infarcts form after birth as a result of the inability of the 
renal parenchyma to sustain the increased work thrown upon it. 

Genital Organs. Aside from anomalies, the organs of generation may 
be the seat of infection, which is acute or chronic, depending upon the 
nature of the infection. 

Osseous System. Osteomalacia, premature ossification, general hyper- 
plasia, and infections of various nature occur. 

" Spontaneous fracture" has been recorded, and is regarded as due to 
uterine contractions and trauma. 

Luxations of the joints are due to anomalous development or oligo- 
hydramnios. 

Oligohydramnios is in causal relation with talipes or similar condi- 
tions. 

Centric Talipes. Centric lesions will also produce them by causing 
muscular contracture. 

Muscular System. Aside from anomalies of development, the muscles 



334 PATHOLOGY OF FhEGNAMJY. 

are Bubjeol t<» the same changes occurring in other tissues due to general 
causes. 

The shi, i shows the characteristic lesion- of acute specific diseases, such 
a- scarlatina, Bmallpox, erysipelas, etc. Syphilitic and tubercular Lesions 
have also been observed. 

(Edema, ichthyosis, and many other Lesions <>f the skin have been 
recorded; hut, as yet, their pathology is entirely obscure. 



CHAPTEE XYI. 

ABOETION AND PREMATURE LABOR. 

Definition and Classification. The term abortion signifies the expul- 
sion of the products of conception before the sixteenth week of gestation, 
at a time when the placenta is not yet fully formed, and hence when it 
cannot be expelled or expressed (Crede's method) in its entirety. 

Premature labor is applied to the delivery of a foetus at any period 
from the time after it has become viable to within a few weeks before 
the normal termination of pregnancy. It is made to cover the period from 
the twenty-eighth to the thirty-sixth or thirty-eighth week of gestation. 

For the intervening period (from the sixteenth to the twenty-eighth 
week) not included by abortion and premature labor, the term " miscar- 
riage" is generally employed. The use of the latter term, though sanc- 
tioned by time and habit, is not satisfactory, as admitted by many authors 
who have submitted to the custom. It would appear that the term 
" immature labor" would be more appropriate. The processes of expul- 
sion at this period of gestation resemble in a measure those of labor at 
full term, and they may be looked upon as constituting a labor in min- 
iature. But the foetus, though it may be born alive, is so immature in 
its development that it cannot be reared — in other words, it is non- 
viable. Hence, the adjective " immature" would fitly denote at once 
the nature of the delivery and the condition of the foetus. 

Assigning the twenty-eighth week as the period of viability is some- 
what arbitrary. For with the modern incubators and improved methods 
of feeding, foetuses born at an earlier period of pregnancy have been 
known to live and thrive. 

Ribemont-Dessaignes and Lepage 1 make the weight of the foetus a 
criterion of its viability. They consider it non-viable if it weighs less 
than 1000 grammes, and viable if it weighs more than that. French 
authors make the following divisions: (1) Ovular abortion, that which 
takes place before the twentieth day. (2) Embryonic abortion, that which 
takes place from the twentieth to the eightieth day. (3) Foetal abortion, 
that which takes place from the fourth to the seventh month. This 
division is confusing and has no practical value. 

Abortion is artificial or spontaneous according as it is or is not evoked 
intentionally. 

Artificial abortion is spoken of as therapeutic when it is done for justi- 
fiable cause, and criminal when it is done for improper or immoral 
reasons. 

Frequency. It is next to impossible to ascertain reliable statistics 
on this point. Many women abort at an early period of pregnancy 
without knowing it, thinking that the menses were merely delayed and 
then came on rather profusely. Again, other women conceal the fact 

1 Ribemont-Dessaignes et Lepage. Precis d'Obstetrique. Paris, 1897. 

(335) 



336 PATHOLOGY OF PREGNANCY. 

from motives of delicacy. The estimates of authorities differ widely. 

According to some writers, abortion occurs once in five or six pregnan- 
cies. Hegar ] estimates the frequency at once in eight pregnancies. 

Whitehead,-' whose statistics are universally quoted, states that thirtv- 
Seven out of every one hundred mothers abort before they reach the age 
of thirty years. His statistics, however, were based upon the lowest 
classes of Irish peasants, who were living in Manchester in great priva- 
tion and amid most insanitary surroundings, and with whom very early 
marriages were the rule. 

Time of Occurrence. Abortion occurs most frequently in the third 
month — that is, between the ninth and sixteenth week of pregnancy. It 
is especially liable to take place at the menstrual dates. It is very 
probable that this greater frequency at the third month and in the begin- 
ning of the fourth month is due to the fact that at this time important 
changes are taking place in the attachment between the ovum and 
uterine wall. It is the period of the formation of the placenta. The 
chorionic villi situated on the periphery of the ovum undergo atrophy, 
while those situated in contact with the uterine wall (the decidua serotina) 
become hypertrophied. 

The extent of surface by which the ovum is attached to the uterus is, 
therefore, decreased, though at the point where it still remains attached 
— the site of the future placenta — it strikes deeper roots into the uterine 
tissues. 

It is commonly believed that early, especially first pregnancies, have 
more frequently a premature termination than those which come after. 
Whitehead 2 observed, however, that the third and fourth pregnancies 
and one or two of the last, those, namely, which occur near the termina- 
tion of the fruitful period, are most commonly unsuccessful. This is 
particularly interesting, inasmuch as Whitehead's observations relate to 
a class of people among whom the girls married at the early age of thir- 
teen and fourteen years. This experience corresponds with that of the 
author with Russian Jews, who also are given to early marriages. 

Etiology. For practical purposes the causes of abortion may be 
divided into those acting through the father, those acting through the 
mother, and those affecting the ovum. 

Paternal. By far the most important and frequent cause of abor- 
tion proceeding from the father is syphilis. It is frequently overlooked 
because the manifestations of the disease may no longer be present, or 
they may never have been so marked as to have excited the attention 
either of the patient or his physician. Tuberculosis, lead-poisoning 
(C. Paul, 3 Pennert 4 ), alcoholism, extreme youth, great old age, excessive 
venery may all act as causative factors. Pibemont-Dessaignes and 
Lepage 5 relate an observation which would go to prove that excessive 
coition may be a cause of abortion. Of thirty cows that were served 
by the same bull within a short period, the fifteen that were served first 
went to full term, the last fifteen all aborted. 

Maternal. General. Under this heading a great variety of con- 

1 Hegar. Monatsch. f. Geburtsh., Bd. xxxi. S. 34. 

2 Whitehead. Abortion and Sterilitv, etc. London, 1847. 

3 C. Paul. Arch. Gen. de Medecine, 1860. 

4 Rennert. Arch. f. Gyn., 1881. 

6 Ribemont-Dessaignes et Lepage. Precis d'Obstetrique. Paris, 1897. 



ABORTION AND PREMATURE LABOR. 337 

ditions are stated, such as youth, obesity, the plethoric and nervous tem- 
peraments, all of which are of rather doubtful potency. The very 
youthful with immature sexual organs are not likely to conceive, and 
abortious in first pregnancies are not common among people that are 
given to very early marriages (Whitehead 1 ). Marked obesity is more fre- 
quently associated with sterility than with repeated abortions. Women 
with very marked or peculiar nervous temperament may abort on 
slighter provocation than others. Severe emotional disturbances, such 
as sudden fright, profound sorrow, etc., may at times bring about an 
interruption of pregnancy. Abortion is rather common in women as 
they approach the end of the fruitful period. 

Traumatism as a cause of abortion must always be accepted with con- 
siderable scepticism. Pregnant women have been known to sustain the 
most severe injuries without aborting. On the other hand, to the most 
trifling accident, such as a misstep or a simple fall, is frequently as- 
cribed by the laity the interruption of pregnancy. 

Major operations (ovariotomy and even myomectomy) have been per- 
formed on pregnant women without any deleterious influence upon the 
course of gestation. Operations on the vulva, however, are said to be 
more dangerous in this regard (Schauta 2 ). Yet the author once excised a 
very much hypertrophied hymen, necessitating extensive suturing of the 
resulting wound, in a young woman in the fourth month of pregnancy, 
and she went to full term. 

Too frequent indulgence in sexual intercourse not only lessens the 
virility of the spermatozoa, as we have already seen, but acts also as a 
traumatism and brings about a hypersemia of the uterus. Hence, abor- 
tion is common in newly married women during the first five or six 
weeks of married life. 

Various constitutional diseases, such as syphilis, tuberculosis, severe 
malarial poisoning (T. G. Thomas 3 ), lead-poisoning (Benson-Baker, 4 
Rennert 5 ), cardiac disease, especially affections of the left orifices, may 
act as etiological factors (A. McDonald, 6 E. Leyden 7 ). Of these syphilis 
is again by far the most common cause. According to Roemheld, 8 27 
per cent, of all interrupted pregnancies are due to syphilis in the mother. 

The acute infectious diseases (especially typhoid) are generally inimical 
to the continuance of the pregnant state. The germs may act directly 
on the foetus through the placental circulation, or the attendant high 
temperature may destroy the foetus (M. Runge 9 ), or placental hemor- 
rhages may occur as a result of the pathological changes set up by the 
constitutional affection (Zweifel 10 ). 

Sea voyages, even in absence of storms, and high altitudes (Sancerotte 
and Jourdanet, quoted by Charpentier) are said occasionally to cause 
premature expulsion of the foetus. 

Drugs. Certain drugs — ergot, savine, quinine, salicylate of sodium 

1 Whitehead. Abortion and Sterility, etc. London, 1847. 

2 Friedrich Schauta. Lehrbuch der Gesammten Gyniikologie. Leipzig und Wien, 1896. 
* T. Gaillard Thomas. Abortion. 1890. 

4 Benson-Baker. Obstet. Trans., London, 1867, vol. viii. p. 41. 
s Rennert. Arch. f. Gyn., 1881 

6 A. McDonald. Obstetrical Journal of Great Britain, 1877. 

7 E. Leyden. Zeitsch. f. klin. Med., 1893. 

8 L. Roemheld. Inaug Diss. Mainz, 1895. 

9 M. Runa:e. Volkmann's klin. Vortrage, No. 174. and Arch. f. Gyn., Bd. xii. S. 16. 
w P. Zweifel. Lehrbuch der Geburtshiilfe, Stuttgart, 1895. 

22 



338 PA TlInLOGY OF PREGNANCY. 

(the author 1 ), and a hosl of others — arc Bupposed to possess the property 
of bringing on abortion. It is doubtful whether they can do this in a 
normal condition of the uterus. When a strong predisposition exists, 
however, quinine and salicylate of sodium should be administered with 

greal caution. 

Local Causes. Backward displacement of the uterus is a very com- 
mon cause (58 per cent., Etoemheld 2 ), in which condition it maybe due 
to the inability of the fundus to rise above the promontory, and then it 

usually takes place between the third and fourth month. The termina- 
tion of pregnancy may, however, occur later, and then it is said to be 
due to the chronic endometritis and metritis that are usually associated 
with the malposition. 

The other conditions of the uterus that may give rise to abortion are 
chronic metritis, chronic endometritis, laceration of the cervix, adhesions 
of the uterus to the pelvic wall or to other adjacent structures, fibromyo- 
mata or malignant growths, immature and abnormal development of the 
uterus (uterus bicornis, pregnancy taking place in a rudimentary horn), 
neighboring tumors, and pelvic deformities, which may interfere with the 
growth of the uterus. Artificial forward fixation of the uterus, either to 
the vagina or to the abdomen, has occasionally been known to produce 
abortion from inability of the fundus to grow, owing to too firm union 
with the vaginal or the abdominal wall. 

Lastly, there are some women who abort over and over again, and in 
whom the most thorough investigation fails to find a reasonable cause. 
To this condition the term " habitual abortion" is applied. To attribute 
the tendency to a hyperaesthetic condition of the uterine system of nerves 
(T. G. Thomas 3 ) or to congestion of the uterus (Napier 4 and others) is 
merely begging the question. By many authors the term habitual abor- 
tion is used interchangeably with repeated abortions. This is mislead- 
ing from an etiological stand-point, to say the least. 

Fcetal. Under this heading are included all the pathological changes 
that may affect the ovum and its envelopes. Here, again, syphilis plays 
an important role by producing changes in the ovum or in the placenta 
which lead to the death of the foetus and to consequent abortion. It 
may kill the foetus directly through causing marked pathological changes 
in important organs, and the membranes may remain unaffected (Zwei- 
fel 5 ). 

Syphilis may be transmitted directly from the father, and the foetus 
die of it without infection of the mother ensuing. According to Napier, 6 
when syphilis is the cause, the death of the foetus occurs most frequently 
between the third and eighth months, very seldom before that time. 

Various diseases of the decidua, placental apoplexy, and the different 
degenerations of the placenta may bring about abortion by causing death 
of the foetus. Polyhydramnios, by causing over-distention of the uterus, 
may lead to premature expulsion of its contents. 

Abnormal insertion of the placenta (placenta prsevia) is very prone to 

1 H. N. Vineberg New York Med. Journ., vol. lix. p. 785. 

2 L. Roemheld. Inaug. Diss. Mainz, 1895. 

3 T. Gaillard Thomas. Abortion. 1890. 

« W. D. L. Napier. Trans. London Obstet. Society, 1890, p. 389. 

* P. Zweifel. Lehrbuch der Geburtshiilfe, Stuttgart, 1895. 

• W. D. L. Napier. Trans. London Obstet. Society, 1890, p. 3S9. 



ABORTION AND PREMATURE LABOR. 



339 



induce abortion, though it generally plays a more important role in the 
production of premature labor. 

Pathology. To describe all the pathological changes of the mem- 
branes and ovum that are observed in abortion would lead us beyond 
our province. We will merely give those that we consider necessary for 
the elucidation of our subject. 

In abortion there is invariably a rupture of the bloodvessels that con- 
nect the ovum and the uterine wall — in other words, of the utero- 
placental vessels. The effusion of blood usually takes place in the 
decidua vera, but not infrequently it forces its way between the decidua 
and chorion, also at times even breaking through the decidua and 
amnion and filling the amniotic cavity with blood. In abortions of 
more advanced pregnancy, after the formation of the placenta the blood 
is effused between the placenta and the uterine wall. In this manner the 
placenta is detached to a greater or less extent from its uterine insertion. 
In studying the pathological anatomy and mechanism of abortion we 
cannot do better than quote Dr. Berry Hart's 1 excellent description: 
Two forms must be considered : (1) Normal or complete; (2) abnormal 
or incomplete. 



Fig. 235. 





Aborted ovum. Deciduse and ovum complete, o. i. corresponds to the decidua situated at the os 
internum ; t.t., to the decidua situated at the openings of the tubes. 



i D. Berry Hart. Trans. Edinb. Obstet. Society, 1890-'91, p. 20. 



340 PATHOLOGY OF PREGNANCY. 

Normal or Complete. There are two varieties depending upon the 
size of the ovum proper covered by reflexa. In the first variety, when 
the ovum is siiKill, the deoidua is separated in its whole extent and is 
expelled with the ovum. This is the exception. 

I n tli.' second variety the decidua vera separates over the lower uterine 
segment, and the ovum proper is covered by reflexa driven down into 

the cervical canal, but remaining attached above by an apparent neck to 
the decidua of the retracting upper segment. The rest of the decidua 

is then separated and the whole expelled. 

Abnormal or Incomplete. The following two varieties may occur : 

1. The foetus alone or the entire ovum with its chorion may be ex- 
pelled through the reflexa. The decidua vera and reflexa are retained or 
expelled later. 

2. The ovum covered by reflexa may be expelled, the apparent polypus 
neck having been snapped. The part thus expelled is often mistaken by 
the practitioner for the entire ovum. He sees an oval sac covered by 
decidua with amnion below this and containing liquor amnii and the 
fcetus. It is really only the ovum proper covered by reflexa, and the 
decidua vera and serotina in the shape of a sac are still in utero. 

Fig. 236. 





1 

Closed. Open. 

Ovum of the first month. The deciduse have remained behind, the amnion 
has broken through the chorion ; natural size. (Winckel.) 

It happens occasionally that the extravasation of blood into the mem- 
branes takes place at different times, allowing the coagulation of the 
blood in strata, thus forming what is known as a blood mole. Should 
the process of abortion be slow in culminating, the coloring matter of 
the blood becomes absorbed, the blood strata undergo partial organiza- 
tion, and there results what is known as a fleshy mole. This may form 
anew a connection with the uterine wall and be retained for an indefinite 
period. 

In incomplete and neglected abortions the retained portion of decidua 
or of placenta may develop into a decidual or placental polypus in the 
following manner. The uterus, through contractions, endeavors to expel 
its contents, the placental residua are thus loosened in some places and 
hemorrhage occurs. The blood is deposited upon the placental remains 
in layers, forming a smaller or larger polypoid mass, which acquires a 
new connection with the uterine tissues. Decidual polypi are formed 
in exactly the same way (Winternitz 1 ). These polypi may remain for 
weeks, or even for months, in the uterus without undergoing decomposi- 
tion and without causing a fetid discharge or elevation of temperature. 

1 E. Winternitz. Sam. Zwanglos. Abhand. aus dem Gebiete der Frauenheilk., Bd. ii. Heft 4. 



ABORTION AND PREMATURE LABOR. 



341 



Winternitz 1 relates a case that came under his treatment six and one- 
half months after the abortion. The removed mass was free from any 
fetid odor. It is these formations that frequently are the cause of irreg- 
ular hemorrhages, continuing for a long time after a supposed complete 
abortion. 

The retained placental and decidual residua do not always behave in 
this benign manner. They may undergo decomposition, and if the 
drainage is not free, as is most frequently the case, owing to the closure 
of the cervix, septic infection of a more or less serious nature may result. 



Fig. 237. 



pi 



f. a. 





Early pregnancy (two months). o.e.,os externum; o. i., os internum; /.a., upper limit of firm 
attachment of peritoneum ; pi., placenta ; d. v., decidua vera ; d. r., decidua reflexa. (Hofmeier.) 

The foetus in cases of abortion is, as a rule, smaller than the period of 
pregnancy would indicate. This is particularly true of cases of fleshy 
mole, where the ovum dies at an early stage. It may then become 
entirely absorbed, or exist merely as a small white strand in the centre 
of the amniotic cavity. In other cases, after undergoing partial macera- 
tion in the liquor amnii, the foetus may become mummified, and be thus 
expelled, or, again, putrefaction may set in and the putrid mass be 
expelled piecemeal. 

Symptoms and Clinical Course. The symptoms of abortion vary at 
different periods of pregnancy. In the first six or eight weeks, pro- 
dromal symptoms are rare. The woman has not yet, as a rule, expe- 



i Ibid. 



342 PATHOLOGY OF I'RKGXAyt'Y. 



rienced any of tin- Bymptoms of pregnancy. The abortion has all the 
characters <>(' a retarded and profuse menstruation, which the patient 
often thinks it is. She loses considerable blood, and frequently passes 
large clots. Her Buffering generally is not great — not more severe than 

that which ordinarily accompanies menstruation. Skene 1 speaks of 
some cases in which the hemorrhage takes place only at night when the 
patient LS lying down. The explanation he offers is that the ovum dies 
and is not expelled, but acts as a valve at the os internum when the 
patient is in the erect position. When, however, " she lies down, it falls 
away from the OS, and a hemorrhage takes place, the blood accumulating 
in the uterus when she is standing or walking about." At times there 
may be considerable uterine colic. If the woman recognizes the fact 
that she has been pregnant she will often state that " every thing" has 
come away in the form of a large fleshy mass, which is usually nothing 
more than a large blood-clot partially organized. At this stage generally 
the ovum is rarely found; it passes off with one of the clots, or with 
the shreds of the decidua. 

On bimanual examination the uterus is found enlarged, especially in 
its antero-posterior diameter, to about double the size of the non-pregnant 
uterus. The cervix may be quite closed or very slightly open. 

In other cases the cervix will be found quite open, and the finger will 
detect just beyond the external os a smooth, globular, elastic mass, appar- 
ently attached to its interior. This, as we have already seen, is the 
ovum driven into the cervix, but arrested in its expulsion by the strong 
muscular fibres of the external os. 

In a third class of cases the uterus will be found slightly, if any, 
larger than normal. The continuance of the hemorrhage in these cases 
will furnish us the only evidence that all the products of conception have 
not yet been expelled. It is important to bear in mind that, though the 
uterus is not enlarged and the cervix is not patulous, the hemorrhage in 
all probability is due to retained decidua, for it is generally stated that 
retained decidua is always indicated by a patulous cervix. We have 
seen cases in which profuse hemorrhage continued for weeks with the 
local conditions just mentioned, and which were due to the presence of a 
fragment of decidua, perhaps not larger than the finger-nail. Diihrssen, 2 
who has had a very extensive experience as the assistant of Gusserow at 
the Charite" in Berlin, says that " the retention of portions of the decidua 
vera is not the exception, but the rule." 

In a very small percentage of cases where the ovum and its membrane 
are virtually expelled, either en masse or separately, the hemorrhage 
ceases in four or five days, and a local examination will detect merely a 
softened uterus, perhaps slightly enlarged. 

After the second month of pregnancy premonitory signs are generally 
present. The patient will complain of bearing-down sensations in the 
lower part of the abdomen, and she will suffer more or less from a feeling 
of weight in the pelvis, from backache, from frequent micturition, and 
from a slight mucous or watery discharge. Pains resembling labor pains 
may precede any marked hemorrhage, though at times there may be con- 
siderable loss of blood before labor pains are experienced. The further 

1 A. J. C. Skene. Medical News, 1884. 

-' Diihrssen. Archiv f. Gyn., Bd. xxxi. Heft 2, p. 161. 



ABORTION AND PREMATURE LABOR. 343 

advanced the pregnancy the more likely will it be that the labor pains 
will precede the hemorrhage, though the opposite may obtain at any 
period of prematurity. 

On local examination the cervix may be found closed or partially 
open, according to the advance the efforts of the uterus have made to 
expel its contents. The uterus will be found to correspond in size with 
the given period of pregnancy, providing the foetus has not yet been 
expelled. The latter fact is readily ascertained from the woman herself 
or any of the attendants, as the foetus has now reached a stage of devel- 
opment which makes it easily recognizable by the laity. 

The placenta may be expelled entire after the delivery of the foetus, 
or it may come away piecemeal — a much more frequent occurrence. In 
the latter class of cases portions of the placenta may remain attached to 
the uterus for an indefinite period, as already stated, causing from time 
to time uterine hemorrhage. In cases of protracted abortion the woman 
shows signs of ill health. She grows more or less anaemic, has a some- 
what haggard appearance, and feels too weak to carry on her usual duties. 
Of course, in cases of incomplete abortion, when the retained products 
undergo decomposition and septic infection occurs, the usual symptoms 
of sepsis manifest themselves, and the temperature usually runs high. 
It must be borne in mind, however; that we may have a severe form of 
sepsis with scarcely any elevation of temperature. These cases are gen- 
erally very treacherous, as the poison acts chiefly on the heart. 

Locally we may find an exudate in Douglas's cul-de-sac or at the 
base of one of the broad ligaments. In other cases there will be the 
local signs of pelvic peritonitis. 

In abortions prior to the second month there is no true lochial dis- 
charge, but rather a sero-sanguineous flow lasting three or four days. 
In the later months the flow resembles more or less that following labor 
at full term, and the more advanced the pregnancy the closer the resem- 
blance. After-pains are not common until after the fourth month. 
Before that period they are usually due to incomplete expulsion of the 
products of conception. 

Involution takes place in less time than after labor at term. Subin- 
volution and the consequent metritis, however, are more common, owing 
to the neglect of the precautions usually observed after normal par- 
turition. 

Diagnosis. At first thought the diagnosis of abortion would seem to 
be an easy matter, but the practitioner will meet with no condition in 
his practice which at times will puzzle him to the same degree. In some 
cases the diagnosis is a simple affair. A woman who has always been 
regular passes one or two menstrual periods, then suddenly is seized 
with profuse hemorrhage, and on examination the cervix is found dilated 
and the finger comes into contact with a globular body — the ovum lying 
within it. Unfortunately, from a diagnostic point of view, such a com- 
bination of conditions is a rare exception. The first two conditions may 
be met with, but on examination the cervix will be found closed and the 
uterus but slightly enlarged. The questions confronting the examiner 
then would be : (1) Has the woman been pregnant ? (2) Has she 
aborted? (3) Is the abortion complete or incomplete? Amenorrhoea 
in a married woman who has always been regular and who is not nursing 



34 I r \ riloLOGY OF PREGNANCY. 

is strong presumptive evidence in favor of pregnancy. Other si<rns 
should be Looked for. A uterus only slightly larger than the non-gravid 
organ would confirm tin- diagnosis of abortion. The third question 
could In- answered only by the presence or absence <>(' hemorrhage, for 
with very few exceptions the hemorrhage will continue more or less 
irregularly bo long as any portion or fragment of decidua or placenta is 

retained in the uterus. Jt is true that in some cases the presence of 
retained products within the uterus will be manifested by a patulous 
cervix, which will readily admit the index finger beyond the 08 inter- 
num, hut the opposite condition, a closed cervix, obtains just as often. 

The occurrence of hemorrhage in the pregnant state is always signifi- 
cant of threatened or aetual abortion. But such hemorrhage may be 

due to other cases. A visual inspection of the cervix with the aid of a 
speculum ought to be made to ascertain whether the blood does not come 
from an erosion of the cervix, from carcinoma, or from a small cervical 
polypus. In some women there is a periodical flow for the first two or 
three months or more of pregnancy. 

Ectopic gestation may be mistaken for abortion. At times nothing 
but a careful bimanual examination (under narcosis if necessary) will 
serve to differentiate the two conditions. 

The points of distinction are: (1) The genital hemorrhage in ectopic 
gestation is more irregular and usually less profuse than in abortion. (2) 
The pain in ectopic gestation is generally more severe, and has the char- 
acteristics of severe colic more than of labor pains. (3) In ectopic gestation 
the patient is likely to suffer from syncopal attacks when rupture takes 
place, and at every recurrence of hemorrhage into the peritoneal cavity. 
(4) The mass formed by an ectopic sac is, as a rule, much more sensitive 
to pressure than an imprisoned gravid fundus uteri. 

It occasionally happens that the gravid uterus enlarges irregularly on 
account of adhesions or of chronic metritis. As this condition is likely 
to lead to abortion sooner or later, it may give rise to the erroneous 
diagnosis of ectopic gestation (Vineberg 1 ). 

In very obscure cases, seeing that symptoms of abortion are present, 
there can be no objection to fully dilating the uterus under narcosis and 
exploring its cavity with the finger. 

Prognosis. In spontaneous abortion the danger to life is very slight. 
The woman may be weakened by the loss of blood, but life is seldom 
endangered. Yet cases have been reported in which death has occurred 
from hemorrhage (Zweifel 2 ). 

Although abortion is but rarely a menace to life, it frequently is the 
starting point, when neglected, of various diseases of the uterus, espe- 
cially of subinvolution, chronic metritis, and endometritis, which may 
lead to invalidism. 

Septic infection from retained products is rare unless the woman has 
been examined by unclean hands, or had an unclean instrument passed 
into the uterine cavity. In the writer's experience, however, abortion in 
sharply retroflexed uteri is rather prone to be attended with septic infec- 
tion. This, no doubt, is due to the circumstance that drainage is very 
markedly interfered with. Sepsis following abortion is not, as a rule, so 

1 H. N. Vineberg. New York Med. Journ., vol. lix. p. 785. 

2 P. Zweifel. Lehrbuch der Geburtshulfe, Stuttgart, 1895. 



ABORTION AND PREMATURE LABOR. 345 

serious a condition as that following labor at full term. On promptly 
emptying the uterus the septic manifestations, as a general rule, readily 
subside. An exception, however, must be made in cases of sepsis fol- 
lowing criminal abortion. Here the course of the affection may be 
virulent and rapidly fatal. 

Treatment. Prophylactic. In order to succeed in the preventive 
treatment a very thorough investigation must be made of each case with 
a view to ascertaining the cause, and the treatment suitable for the con- 
dition found must be instituted. 

If retroversion be present, a suitable pessary should be introduced 
after the uterus has first been replaced to its proper position. The case 
should be carefully watched, especially during the third month and the 
commencement of the fourth, when the fundus rises out of the pelvis. 

After this the pessary may be removed. Chronic endometritis and 
laceration of the cervix call for appropriate treatment, which, of course, 
must be carried out before conception takes place. When uterine adhe- 
sions are the cause careful massage and stretching of the adhesions, 
followed by suitably placed tampons, may be attended with success. 

The pelvic massage may be carried out even during pregnancy; the 
manipulations, of course, must be conducted with the greatest gentleness 
and caution. 

If syphilis be suspected, both parents should be subjected to a long- 
continued course of antisyphilitic treatment, and in the mother the 
treatment should be continued during the whole pregnancy. 

Nervous diseases, such as chorea, etc., must be combated by the 
proper remedies. 

In cases of habitual abortion, without any ascertainable cause, the 
woman should be enjoined to remain in bed during the time when the 
menses would normally recur. The rest in bed should be absolute, the 
patient not being allowed to get up to void urine or feces. Emotional 
excitement of all kinds should be prevented. Zweifel 1 states that he 
has met with success in some cases by entirely interdicting sexual inter- 
course during the whole pregnancy. Some authors speak favorably 
of the internal administration of potassium chlorate. The writer has 
met with apparent success with this form of treatment in a few cases. 
The salt is administered in five-grain doses, freely diluted, three times 
a day, and is to be given during the whole period of gestation. It is 
said to act by diminishing uterine irritation and congestion, and also by 
increasing the oxygen of the blood in the mother (Sir J. Y. Simpson 2 ). 
Viburnum prunifolium has been highly lauded in habitual abortion by 
E. J. Jenks. 3 He advises from a half teaspoonful to a teaspoonful of 
the fluid extract four times a day, beginning at least two days before 
the menstrual date, and continuing it for two days longer than the 
periods usually last. Pregnant women in whom the habit of abortion 
exists should not be allowed to go on long railroad journeys, nor on a 
sea voyage. In these cases it is best that at least a year elapse after the 
last abortion before pregnancy again occurs. Physiological rest of the 
sexual organs for a long period occasionally has a happy effect. 

1 P. Zweifel. Lehrbuch der Geburtshiilfe, Stuttgart, 1895. 

2 Sir J. Y. Simpson. Obstet. Memoirs. Edinburgh, 1865, vol. i. p. 460. 

3 E. J. Jenks. Trans. Amer. Gym Soc, vol. i. p. 130. 



;;|,; PATHOLOGY OF PBEQNANOT. 

Treatment of Threatened Abortion. 'Flic abortion may be arrested BO 
Long as the death of the ovum has not occurred. But as it is next to 
impossible to determine this pointy we are forced to act, in great measure, 
empirically. If the hemorrhage has been moderate more particularly 

if the cervix has not yet dilated to any extent, we should direct our 

efforts to staying the threatening event. 

It Is rarely that we will meet with Buccess after dilatation of the 
cervix to the extent of admitting the index-finger has taken place. 
Still, even with this degree of cervical dilatation our efforts may occa- 
sionally be rewarded by seeing the process arrested, the cervix close 
again, and the gestation go on to full term. 

The patient must be put to bed in a cool, darkened room and absolute 
rest enforced. She should not be allowed to sit up for any purpose what- 
soever. The diet should be bland and cool. No one but the nurse and one 
other attendant should be admitted into the sick-room. The remedy 
which forms the sheet anchor in this class of cases is opium in some form. 
A good way of administering it is in the form of rectal suppositories, each 
containing one grain of the aqueous extract. One may be slipped into 
the rectum every four or six hours. If, when first seen, the patient is 
suffering severe pain it is good practice to administer at once a hypo- 
dermic injection of morphine (gr. one-sixth to one-fourth). Viburnum 
prunifolium in half-drachm or drachm doses every six or eight hours 
acts as a sedative to the uterus and constitutes a valuable adjunct to the 
opium treatment. If the hemorrhage is profuse the patient's hips should 
be elevated by a couple of pillows, and cold cloths cautiously applied to 
the vulva. The application of ice-cold cloths to the hypogastrium is not 
advisable, owing to the danger of exciting uterine contractions. The same 
objection applies tq the employment of vaginal tampons or gauze packing. 

The foregoing treatment should be continued until all hemorrhage and 
pain have entirely disappeared for at least two days. Great caution 
should be exercised after the cessation of the symptoms in allowing the 
patient to be up and about, or to resume her duties. On the reappearance 
of the slightest discharge of blood or on the return of the pains, the 
patient should be made to go back to bed at once. 

When the threatened abortion is due to the incarceration of the fundus 
below the promontory, the patient should be placed in the knee-chest 
position and the cervix and vaginal vault exposed by lifting up the pos- 
terior vaginal wall with a good-sized Sims' s speculum. The cervix is 
then caught with a tenaculum and gently drawn forward and down- 
ward while pressure is made against the fundus in the proper direction 
with a large wad of cotton held in an ordinary uterine dressing-forceps. 
In the majority of cases the manoeuvre will succeed in releasing the 
fundus and making it clear the promontory. A couple of large, firm 
tampons should then be placed in the posterior vaginal fornix to main- 
tain the fundus in the proper position. It may be necessary to repeat 
this treatment daily for several days, until all danger of the fundus falling 
back into the faulty position has disappeared. The patient need not 
necessarily stay in bed. 

Treatment of Actual Abortion. When, in spite of the foregoing treat- 
ment, the symptoms persist and the abortion becomes inevitable, or 
when the case at the outset shows evidences that it would be useless 



ABORTION AND PREMATURE LABOR. 347 

to attempt to arrest the process, our plan of treatment must be different. 
There is no further need of keeping the patient under so rigid restric- 
tions. 

The treatment of actual abortion still seems to be a disputed field. 
Some authorities (Dtihrssen, 1 Fehling 2 ) strongly urge active interference 
at once. Others (Lusk, Winckel) favor an expectant plan of treatment, 
and would only interfere as necessity arises from hemorrhage or sepsis. 
It is the writer's custom to follow a course of action which lies about 
midway between these two apparent extremes. 

For the purposes of treatment it is well to divide the cases into early 
abortion (before the tenth week) and late abortion (from the tenth to the 
sixteenth week). 

When called to a case of early abortion, and there is evidence that the 
ovum has already escaped, and there is but a slight flow of blood which 
has lasted a few days only, we can afford to wait a day or two longer 
to see whether the hemorrhage will entirely cease of itself. Of course, 
there must be an entire absence of febrile symptoms. The patient should 
be kept in bed, and the administration of ergot (5ss. t. i. d.) is advisable. 
While the total expulsion of the ovum and its membranes is an excep- 
tional occurrence, still in a fair proportion of the cases in which the 
ovum breaks through its envelopes and is expelled alone or with a por- 
tion of the decidua, the remaining portions of the decidual residua are 
cast off either by uterine contractions or with the scant lochial secretions 
that follow. 

In the same class of cases, if the hemorrhage be profuse, or even if 
it be scanty, but has continued now and then for several days, the proper 
course to pursue is to curette without further delay. In these cases, as a 
rule, the hemorrhage is due to retained decidua which is firmly adherent 
to the uterine tissue, and no amount of uterine excitants will stimulate 
the uterus to such a degree as to enable it to extrude the decidua. It is 
just in these early cases that it is often difficult to know whether the 
ovum has already been cast off or not. When in doubt in this regard 
it is good practice to decide in favor of curettage at once. 

The operation when properly done — and every practitioner ought to 
know how to do it properly — is so free from danger and accomplishes 
the object in view so satisfactorily that the benefit of the doubt may be 
cast in its favor. The facts should always be plainly stated to the 
patient, and if she elects to wait to see what nature (perhaps with ergot) 
will accomplish, she must do so on her own responsibility. During 
the waiting period, if the hemorrhage be at all profuse, the vagina 
should be tightly packed with iodoform gauze, which may be left in situ 
for twenty-four or forty-eight hours. It must not be forgotten that all 
contact with the interior of the vagina must now be carried out under 
strict aseptic or antiseptic precautions. 

In another class of cases, forming only a very small percentage, at the 
first examination the ovum is found enveloped in some of its membranes 
lying in the cervical canal. 

In some of these cases the ovum is easily removed by hooking the 
finger above it and drawing it down ; in others again, the external os is 

i Dtihrssen. Archiv f. Gyn., Bd. xiii. Heft 2, p. 161. 
2 Fehling. Archiv f. Gyn., Bd. xiii. p. 222. 



348 PATHOLOGY OF PREGNANCY. 

bo rigid and unyielding that its lips may bave to be cut before the ovum 
can be extracted. An ordinary placental forceps will at times prove 
very serviceable in Beizing the ovum and twisting it off as one would an 

ordinary polypus. I n the majority of these cases any further interference 
will he unnecessary. But if the hemorrhage should nut promptly cease 
after the above procedure the uterus should he subjected to a thorough 
curettage. 

In a third class of cases there may be unmistakable evidence, in the 
circumstance that the uterus corresponds in size to the period of gesta- 
tion, that the ovum and all its membranes are still within the uterine 
cavity. Two courses arc offered: (1) To anaesthetize the patient, forci- 
bly dilate the uterus with branching dilators, and thoroughly empty the 
uterus, he it with the fingers alone or with the curette alone, or with a 
combination of both; and (2) to pack the cervix and vagina with iodo- 
form gauze, and wait for twenty-four or forty-eight hours to see if 
nature will be able to complete the process. The author's custom is to 
adopt the first course, unless the patient strenuously objects to it. The 
objection that may be raised against this plan of treatment is that it 
usually necessitates reliance upon the curette alone, as it is not often 
that the cervix can be dilated to the extent that one or two fingers may 
be passed into the uterine cavity. Should any one, however, not have 
sufficient confidence in his skill to use the curette in this manner, the 
second course may be pursued in part. The packing can be made to 
serve the double purpose of arresting the hemorrhage and dilating the 
cervix. After the lapse of twenty-four or forty-eight hours the cervix 
will usually be found to have undergone sufficient dilatation to admit 
one or two fingers, with which the greater part of the uterine contents 
may be removed. The gentle use of the curette will succeed in bringing 
away the remainder. The employment of any form of tents to dilate 
the cervix is unsafe and unreliable practice. 

A great deal of discussion has taken place as to the relative merits of 
the finger and the curette for emptying the uterus in abortion. It 
really matters little which is used, so long as the products of concep- 
tion are totally removed. In a great number of cases it is impossible 
to obtain such dilatation of the cervix as to admit the introduction of 
one's finger. On the other hand, even when the finger can enter the 
uterine cavity it is not often possible by this means to bring away all the 
contents. In these cases it is the writer's practice to remove as much as 
possible with the finger, and then to supplement it with the use of the 
curette, employing the finger from time to time to ascertain if there is 
still anything left behind. 

In late abortions the general line of treatment resembles more or less 
closely that just described. At this period, however, we do not meet 
with the same difficulty in determining in a given case whether or not 
the foetus has been expelled. . It is no longer possible for it to escape 
without exciting the notice of the patient or the attendants. If the 
foetus be still within the uterus it is a good plan to pack the vagina with 
iodoform gauze, pushing as much of the gauze within the cervix as pos- 
sible, even should the hemorrhage be not profuse. The cervical and 
vaginal packing has the effect of exciting uterine contractions, bringing 
about cervical dilatations, while at the same time it forms a safeguard 



ABORTION AND PREMATURE LABOR. 349 

against the occurrence of hemorrhage. At the end of twenty-four hours 
the packing should be removed, and if the cervix be found dilated the 
uterus should be emptied with the patient fully anaesthetized. In extract- 
ing the foetus care should be taken not to tear the trunk away from the 
head, the delivery of which may occasion considerable difficulty. This 
accident, however, will happen at times, no matter how careful we 
may be. It is a good plan in these cases to depress the uterus with one 
hand above the symphysis, and thus fix the round ball-like body, while 
with the finger or fingers of the other hand in the uterus a hole is bored 
into the head, which thus being hooked into may be easily extracted. 
When it cannot be thus delivered it may be easily broken up with the 
fingers and removed piecemeal. In carrying out these manoeuvres care 
ought to be exercised not to lacerate the soft uterine walls, an accident 
that need never occur, and one which the author has never met with, 
although he has resorted to this course on several occasions. The secun- 
dines in the majority of cases can next be removed with the fingers in 
the uterus, being aided by the other hand above the pubis, with which 
the uterus is depressed and held in a steady position. When the secun- 
dines cannot all be removed in this manner, the interior of the uterus 
may be gently scraped with a large partly sharp curette — Munde's or 
Lusk's (H. J. Garrigues 1 ). 

If it be found that the foetus has already been delivered, but that the 
secun dines are still retained, the latter should be removed at once in 
the manner just described, without waiting for the occurrence of hemor- 
rhage or sepsis before interfering. If the cervix be not sufficiently 
dilated, forcible dilatation should be practised, either with the finger or 
a steel divulsor. 

In all cases after emptying the uterus its cavity should be thoroughly 
irrigated with plain sterilized water, lysol (1 per cent.), carbolic acid 
(2 per cent.), creolin (J per cent.), or corrosive sublimate (1 to 2000 
or 3000). When using the latter agent an irrigation with sterilized 
water should follow. The toxic effects of corrosive sublimate solutions 
are due not so much to absorption during the irrigation as to the fact 
that a certain amount of fluid always remains behind in the uterus and 
is in part absorbed before it can drain away. 

At all periods and in every stage of abortion where there are any 
indications of sepsis, as manifested by elevation of temperature and 
rapidity of the pulse, or by a too rapid pulse, the temperature remaining 
normal or only slightly above it, active interference is called for at once. 
A day's delay or even one of several hours may allow a mild sepsis to 
develop into one of a serious nature such as may be beyond our power 
to control. As a general rule, the sepsis that occurs in the course of an 
abortion is readily amenable to the proper treatment, which consists 
in emptying the uterus thoroughly, and following this up with irriga- 
tions along the lines already laid down. An exception to the above 
rule is the sepsis frequently seen in criminal abortions, which may 
run as foudroyante a. course as the severer sepsis following labor at full 
term. 

Should the symptoms of sepsis not subside completely under the fore- 

1 H. J. Garrigues. Medical News, Nov. 6, 1897. 



850 PATHOLOGY OF PREGNANCY. 

going plan of action, the uterine cavity should be irrigated again, and the 
irrigations he repeated every four, six, or eight hours, according to the 
severity of the case. It will also be necessary to dilate the cervix from 
time to time, as it has a strong tendency to contract, and thus interfere 
with free drainage. Packing the uterine cavity in these cases is abso- 
lutely to be avoided, and even a strip of gauze in the cervix to favor 
drainage is, in our opinion, a snare and a delusion. There -till seems to 
be a fear Lurking in the minds of some distinguished authorities (Lusk, 1 
Garrigues, 5 and others), that curetting a highly septic uterus will destroy 
the protective wall which nature forms, the so-called u granulation 
zone" of Bumm. 3 The fear is founded upon a supposed fact which 
does not in reality exist. The "granulation zone" was observed by 
Bunini only in the milder cases of sepsis, in the so-called eases of 
'* putrid intoxication;" in the severe forms of infection no such protec- 
tive zone was seen, but the micro-organisms were found penetrating the 
whole thickness of the uterine wall and on the peritoneum. If Bumm's 
observations were to guide us in our clinical work we would refrain from 
curetting the mild cases of uterine sepsis, while in the severe forms they 
would constitute no contraindication, for we could not destroy that which 
did not exist. 

The patient from the outset should receive the general treatment 
usually applied to septic conditions following parturition at term, and as 
this is fully described in another part of this treatise, it will be unneces- 
sary to repeat it here. 

The treatment of immature labor is the same as that for premature 
labor, which will receive attention later. There is probably a greater 
tendency for the placenta to be retained in the uterus than when preg- 
nancy is interrupted at a more advanced period. If there be no hemor- 
rhage, nor any elevation of temperature, and the pulse is normal, there 
is no harm in waiting twenty-four or forty-eight hours to see if the 
uterus will of itself be able to expel the placenta. But to tampon the 
uterus and vagina during this period, as recently recommended by Gar- 
rigues, 4 would seem to be an unsafe procedure and one likely to favor 
sepsis. If such a contingency arise in country practice much the safer 
plan is to remove the placenta manually at once should attempts to ex- 
press it by Crede's method fail. 

The patient might be seized with a dangerous hemorrhage in the physi- 
cian's absence, which might prove disastrous before he could reach her. 
Beside, there is a prevalent prejudice among the laity that is not en- 
tirely unfounded against leaving the after-birth in the uterus for any 
length of time after the foetus has been delivered. 

Curettage. The operation of curetting the uterus may now be de- 
scribed. The description may be premised by saying that the same care 
in asepsis and antisepsis ought to be exercised in regard to it as to that 
of any major operation. It is only by making this a routine in every- 
day practice that infection can be averted in cases which have not already 
been rendered septic. The operation should not be followed by rise of 

1 Wm. T. Lusk. The Amer. Journ. of Obstetrics, 1896, vol. xxziii. 

2 H. J. Garrigues. The Medical News, Nov. 6, 1897. 

3 E. Buram. Archiv. f. Gvn., Bd. xl Heft 3, p. 398. 
* H. J. Garrigues. The Medical News, Nov. 6, 1897. 



ABORTION AND PREMATURE LABOR. 351 

temperature in a clean case, and when it is, we must, as a rule, assume 
that we have introduced the pathogenic germs. 

The patient should be placed upon a table in the lithotomy position. 
This can be attained by the various leg-holders in the market, or, in 
the absence of these, by twisting a sheet diagonally, tying one end around 
the thigh near the knee, making it pass over one shoulder and under- 
neath the other, and tying the other end around the opposite thigh, both 
thighs being flexed upon the abdomen. The vulva and surrounding 
parts should be thoroughly scrubbed with an ordinary hand-brush and 
with warm water and green soap. Shaving off the hairs of the vulva 
may or may not be done. It is the writer' s practice to do it. The hands 
should then again be washed before undertaking to scrub the vagina, 
which ought to be done thoroughly but not roughly. A gauze compress 
held in uterine forceps serves this purpose very well, aided from time to 
time with two fingers of one hand. There is nothing better to reach 
all the corners and crevices of the vagina than the fingers, or the half 
hand when there is a wide orifice. The vagina and vulva are then freely 
irrigated with sterilized water, which may be followed by an irrigation 
with some antiseptic solution. The legs should now be covered with 
sterilized cotton stockings or, what answers just as well, sterilized pillow- 
slips, and sterilized towels be placed upon the lower part of the abdomen, 
over the buttocks, and beneath the nates; in short, every part in the 
immediate vicinity of the operating field except the vaginal orifice should 
be covered with sterilized cloths. While this is being done by the nurse, 
the operator should again subject his hands to a thorough scrubbing and 
washing. A weight-speculum (Edebohls') retracts the posterior vaginal 
wall and exposes the cervix, which is seized with one or two volsellse. 
No traction should be made with these, their purpose being merely to fix 
and steady the uterus. With one of the branching dilators the cervical 
canal is gradually dilated. Hegar's cervical bougies or Hanks' steel 
dilators may first be used, and the dilatation increased by the branching 
instrument. In some cases the cervix is very rigid, and to overcome this 
considerable force will be required; in others again, the tissues are very 
friable, and here the greatest caution must be exercised, or a serious tear 
extending into the uterus may be readily inflicted. After obtaining all 
the dilatation possible within safe limits, an attempt may be made to 
introduce the index-finger of one hand. The finger may be able to 
locate the situation of the retained products, and perhaps remove them. 
In this procedure the instruments should be removed and the uterus 
depressed with the other hand above the symphysis. 

In many cases it will be impossible to dilate the cervix so that the 
finger may be introduced, as has already been stated. In these the 
curette alone will have to serve our purpose, and the sharp instrument 
is the one we invariably employ. Very many object to the use of a 
sharp curette as being too dangerous, and recommend a dull one. It 
seems to us that less harm is likely to be done with a sharp than with a 
dull instrument, for we can gauge the necessary force to employ more 
accurately with the former than with the latter. It must be admitted 
that the uterus may be perforated with either instrument, even in skilled 
hands, but ill results need not necessarily follow. When it is learned that 
the accident has occurred, the remainder of the uterus may still be 



352 IWTllOLOdY OF rilKUXAXCY. 

ou retted, care being taken to avoid the point of injury, and no irrigation 
should be employed. Should any inflammatory reaction follow, an ice- 
bag may be placed over the lower part of the abdomen and opium 

Suppositories administered. There IS no excuse for some of the serious 
accidents that are occasionally reported. They are not inherent in the 
operation, but are due to a combination of brute force and gross igno- 
rance on the part of the operator. 

The three accidents reported by M. J). Mann 1 were due not to the 
use of the curette, but to the branching dilator, which in two of the 
eases evidently perforated the uterus when being introduced, and the 
perforations were increased in size by introducing forceps which seized 
coils of intestine. In Mann's 2 own case the tear in the uterus was 
effected with GoodelPs dilators. Still he thoroughly curetted the uterus 
after the accident, and the patient made a good recovery. Why these 
cases should be used as a warning against the use of the curette, as Mann 
seems to think, it is difficult to understand. 

Injury to the uterus in curetting is more frequently inflicted by push- 
ing the curette through the uterine wall than in the act of scraping. 
By bimanual examination the size of the uterus, and consequently the 
depth of its cavity, can be fairly well estimated. By this means also the 
direction of the canal can be ascertained. In introducing the curette, 
therefore, one ought to know in which direction to carry it and when it 
may be expected to reach the fundus. No force whatever should be 
employed in this manoeuvre. 

Having passed the curette to the fundus the wall is scraped on with- 
drawing it, and one soon learns in which region of the uterus the retained 
products are situated. The curetting at this point may be done more 
vigorously, but a close watch must be kept upon the nature of the tissues 
removed. With a little experience one readily learns when the curette 
has reached the harder uterine tissue. In cases in which the uterus is 
very soft, the instrument, if a sharp one, need merely to be gently drawn 
over the surface. It is particularly in the cornua that decidual and 
placental residua are likely to be retained. These regions of the uterus, 
therefore, call for especial attention. When the operator feels satisfied 
that everything has been removed, the uterine cavity should be irri- 
gated as stated above, but packing the uterus or the vagina with gauze 
ought to be avoided except in those instances in which uncontrollable 
hemorrhage follows the operation. 

It is a good plan to administer ergot for the following four or five 
days or longer, in order to favor involution. The patient should be kept 
in bed for six or seven days, at the end of which time the uterus should 
be examined bimanually to ascertain if involution has progressed satis- 
factorily. 

Missed Abortion and Missed Labor. 

Missed Abortion. It occasionally happens that the foetus dies and the 
progress of gestation ceases, but the products remain within the uterus 
for weeks or even months. To this phenomenon the term "missed 
abortion" is applied; a similar condition occurring when pregnancy has 
arrived at full term is called " missed labor." 

1 Iff. D. Mann. The Amer. Journ. of Obstetrics, 1895, vol. xxxi. p. 603. - Ibid. 



ABORTION AND PREMATURE LABOR. 353 

Missed abortion must also imply a comparatively quiescent state of 
the uterus, in order to distinguish it from prolonged abortion (W. Japp 
Sinclair 1 ). 

As a rule, at the time of the death of the foetus a slight hemorrhage 
occurs; but this may be absent, as it was in the three cases reported by 
Sinclair. It is seldom necessary to interfere manually in these cases. 
According to Sinclair, 2 " missed abortion" does not occur among young 
and presumably vigorous primiparse. The writer's patient was young, 
but of rather delicate build, and had mitral stenosis. The same autho- 
rity states that there is seldom a history of previous abortions or reten- 
tions in these cases ; in our case there had been. 

Missed Labor. In this condition there may or may not be some of 
the phenomena of ordinary labor at the time parturition should nor- 
mally occur. If they do occur, the pains and the discharge are very 
slight, and soon cease. 

The fate of the retained child varies very much. In some instances 
when the membranes are not broken and no atmospheric air enters the 
amniotic cavity, the foetus may remain fresh for a long time; in others 
it becomes macerated and undergoes mummification. In other cases 
again, when atmospheric air does enter the cavity, putrefactive changes 
set in, giving rise to the condition known as physometra. Sometimes 
the soft parts of the foetus disappear through liquefaction, and the bones 
are a long time in being discharged; sometimes they pass through the 
uterine walls and appear in the vagina, rectum, or bladder, or they set 
up in their passage an inflammatory process about the uterus, leading to 
a pelvic abscess. 

It is generally recommended to wait a few weeks in cases of missed 
labor, in the hope that the uterine contents may come away of themselves 
without artificial interference. Should this plan be pursued the patient 
ought to be carefully watched, and on the slightest manifestations of 
fever or symptoms of sepsis the uterus should at once be emptied of its 
contents. One should always decide in favor of artificial interference as 
soon as there is positive evidence of the death of the foetus. The woman is 
exposed to less risks by the adoption of this plan of procedure, carefully 
conducted, than she would be by carrying about a dead foetus for an 
indefinite period. 

In every case after the delivery of a dead foetus, it is a good plan to 
follow the expulsion of the placenta and membranes with a copious 
intra-uterine douche of some mild antiseptic solution. 

The administration of ergot for some days after the emptying of the 
uterus is particularly advisable, as the uterus in these cases has a tendency 
to inertia and retarded involution. 



Premature Labor. 

The factors already stated as being causative of abortion may like- 
wise act at a later stage of gestation, and be the means of prematurely 
terminating the pregnancy. 

i W. Japp Sinclair. Brit. Gyn. Journ., 1887-'88, p. 201. 2 ibid. 

23 



35 \ PA run LOGY OF PREGNANCY. 

The most common causes, however, arc faulty insertion of the placenta, 
albuminuria, and syphilis. 

In 357 oases analyzed by Vallais 1 faulty insertion of the placenta was 
present in L79 cases, albuminuria in 39 cases, and syphilis in 33 cases. 

In 82 cases UO cause Could l>e ascertained. 

Treatment. When a woman is threatened with premature labor and 
the foetus is still alive, one would naturallv endeavor at first to avert it, 
Unless there were marked albuminuria and threatening symptoms of an 
eclamptic seizure, or in the presence of a faulty insertion of the placenta 
(placenta previa and placenta marginalis) ; in such contingencies one 
would, on the contrary, hasten the event. Opium must now be given 
with some caution, for fear of its unfavorable effect on the foetus. A 
combination of potassium bromide and chloral hydrate (aa gr. xv.) acts 
well in these cases. Should one's efforts fail and the labor go on 
progressing, its management is precisely similar to that of labor at term, 
and hence does not call for special attention here. 

Franyois Vallais. These, Paris, 1893. 



CHAPTER XVII. 

ECTOPIC GESTATION. 

Definition. When an impregnated ovum becomes fixed and begins to 
develop outside of the uterine cavity, ectopic gestation or extra- uterine 
pregnancy is established. 

Varieties. The classification of ectopic gestation into tubal, ovarian, 
and abdominal, made by Biauehi in 1741, and simplified by Boehmer in 
1752, remains practically unchanged, as far as the primary forms are 
concerned, unto this day. The terms primary and secondary, as applied 
to ectopic gestation, refer to the conditions before and after rupture or 
change of location of the ovum. As will hereafter be shown, rupture 
and change of location occur in the majority of cases, the anatomical 
relations of the ovum to its surroundings being thereby altered. The 
cases of primary ovarian and abdominal gestation are, however, so rare 
and so difficult of absolute demonstration, that the general statement may 
be admitted that every ectopic pregnancy is primarily tubal. 

Tubal pregnancies are classified according to the site of attachment of 
the ovum as (1) interstitial, the so-called tubo-uterine; (2) true tubal, 
isthmial, or ampullar, and (3) infundibular or tubo-ovarian. 

1. Interstitial Pregnancy refers to that class of cases in which the ovum 
develops in that portion of the tube which passes through the wall of the 
uterus, or in a diverticulum from that part of the tube. 

2. True Tubal Pregnancy is the variety in which the ovum develops 
in the free portion of the tube, without protrusion into either the uterine 
or the abdominal cavity. When it occurs in the inner portion of the 
tube, it is termed isthmial, and when in the outer, ampullar. 

3. Infundibular Pregnancy includes the cases in which the ovum is 
lodged and developed in the infundibulum of the tube, and prevents 
closure of its abdominal ostium. The cases of this variety in which the 
ovum is attached to the ovary are ordinarily styled tubo-ovarian. 

Ovarian and Abdominal Pregnancy are terms applied to those cases of 
extra-uterine pregnancy which are supposed to originate and develop in 
the ovary or in the abdominal cavity. 

Anomalous Varieties. Ectopic pregnancy may occur in an accessory 
fimbriated extremity (see Fig. 238), or in a diverticulum from the Fallo- 
pian tube (see Fig. 239). Both of these varieties are to all intents and 
purposes tubal pregnancies. 

Cornual Pregnancy occurs when the seat of gestation is in the undevel- 
oped horn of a bicornate uterus. This anomaly is due to unequal devel- 
opment or lack of proper union of the two Mullerian ducts. Although 
cornual pregnancy in its course and termination resembles extra-uterine 
pregnancy, it cannot properly be classed as a variety of the latter, but 
is a true uterine pregnancy, which, by reason of the malformation of the 
organ, eventually becomes pedunculated and walled off from the main 

(355) 



356 



PATHOLOGY OF PREGNANCY. 



cavity. Jt is, however, surrounded by uterine mucosa, and the decidua 
is formed in the impregnated cornu. 

Anv attempt t<> classify the secondary forms of extra-uterine pregnancy 
leads to confusion. In this connection the term secondary means Bubse- 



Fig. 238. 




Ectopic gestation in blind accessory fimbriated extremity of right tube. 
Fig. 239. 




Left Fallopian tube with ectopic gestation in diverticulum. 
a, a. Gestation sac communicating with diverticulum. 

quent to rupture or displacement. When an ovum breaks through its 
outer investing structures without rupture of the sac, its development 
is not necessarily arrested, although its anatomical relations may be 



ECTOPIC GESTATION. 



357 



changed. A special name has been given to each of the varied locations 
of the displaced ovum, and to this fact is due the confusion of terms. 



Fig. 241. 




Fig. 242. 




Sections made from case represented in Fig. 239 on each side and at extremity of diverticulum. 

They show distinctly the separate canals and the narrowing of the diverticulum as it approaches 

the uterus. 

a, a. Lumen of Fallopian tube, b, b. Lumen of diverticulum. 

The secondary forms are simply complications of the primary varieties 
before described, and are not deserving of separate classification. The 



358 



lwruoLOGY or rnr.cNANCY. 



variooa names applied to these forme arc in bo common use, however, 
that they can hardly be ignored. They will, therefore, be mentioned 
later. 

Etiology. The point at which the spermatozoa meet and impregnate 
the ovum is not known. Some authors claim that the spermatozoa pene- 
trate the Fallopian tube with ease, and that impregnation usually occurs 

in this location. This claim is stated by many other- to be a mere con- 
jecture, unsupported by facts, and these authors claim that impregnation 
takes place within the uterus. 

The habitual ease with which spermatozoa pass from the orifice of the 
vagina through a virgin os uteri, oftentimes occluded by mucus, into the 
uterus, and the occasional cases in which, despite frequent disturbance, 
they travel from outside the vulva, through an almost imperforate hymen, 
up a vagina containing secretions destructive to their life, and finally pass 
uninjured into the uterus, make it reasonable to suppose that they may 
go with not less ease up the uterus into the Fallopian tube, and even 
into the abdominal cavity. There is no reason to believe that the cili- 
ated epithelium of the tube, which assists the migration of the ovum 



Fig. 243. 




Left Fallopian tube with diverticulum reconstructed. 
a, a. Diverticulum. 

toward the uterus, obstructs the progress of the spermatozoa, nor is it 
probable that the peristaltic action of the tube toward the uterus would 
check the march of so minute a body as a spermatozoon. 

In the lower animals the presence of spermatozoa in the pelvic cavity, 
as well as in every portion of the genital tract, soon after coitus, has 
been repeatedly demonstrated. Moreover, the migration of the ovum 
in the human female has apparently been proved by the occurrence of 
pregnancy in patients in whom the ovary of one side and the tube of the 
opposite side had been removed. If this migratory range for both ovum 
and spermatozoa be admitted, the mechanical theory of ectopic gestation 
is thereby made reasonably plain. The inference would be, however, 
that such gestation would be more common, and primary abdominal 
pregnancy the most frequent form. This, we know, is not a fact, for 
even the existence of this latter variety can hardly be established. 

There is then something characteristic of the tubal mucosa which 
allows the implantation and growth of a fertilized ovum or some element 
that inhibits its growth or destroys it in the pelvic cavity. Clarence 



ECTOPIC GESTATION. 



359 



Webster explains this by claiming that, beside the mechanical condition 
which retains the ovum, there is need of " the occurrence of certain 
necessary reactions in the mucosa, caused by genetic influence and pro- 
ducing decidual changes, such influence existing by reason of a reversion 
in the tubal mucosa to an earlier type in mammalian evolution/' 

A pathological condition of the ovum may favor a premature adhesion 
to the wall of the tube before the uterine cavity is reached. Pathological 
or abnormal conditions of the tube itself, however, form undoubtedly 
the most important factor in the causation of ectopic gestation. Chief 
among these may be mentioned the following: Congenital deviations from 
normal type, such as exaggerated convolutions (Fig. 244), diverticula 
(Figs. 239 and 243), and atresias; sagging and attachments by adhe- 
sion, resulting in distortion of the tube; pressure from adjoining organs; 
thickening of tubal walls, either congenital or acquired ; diminishing 
peristalsis; desquamative salpingitis or hyperplasia, destroying the cilia, 
producing atresia; growths, either in the canal or the walls; obscure 
conditions, preventing coaptation of the fimbriae with the ovum or ovary. 

Fig. 244. 




Infundibular ectopic gestation with Fallopian tube, showing exaggerated convolutions. 



Pathology. Changes in the Uterus. This organ begins to enlarge, both 
as to its cavity and walls, simultaneously with the establishment of preg- 
nancy in the tube. It continues to enlarge, and up to the fifth month is 
usually one-third to one-fourth smaller than in an intra-uterine pregnancy 
of the same age. The enlargement may continue after this time, but at 
a less rapid rate. Rupture of the tubal pregnancy, when followed by 
death of the ovum, checks the growth of the uterus, and is soon followed 
by involution. When, however, death of the ovum does not take place, 
the uterus may continue to enlarge, though not to the same extent as 
before the accident. The uterus of an extra-uterine pregnancy at full 
term usually measures from four to six inches in depth. Involution of 
the uterus does not commence until the foetus is dead, and decrease in the 
size of the uterus is an indication that this has occurred. In general 
terms, it may be stated that the more remote the place of implanta- 



360 



PATHOLOGY OF PREGNANCY, 



tion of the ovum from tin- uterus, the less the increase in size of that 
organ. 

Decidua. One of the most notable changes in the uterus in ectopic 
gestation i> the Formation of a decidua. It partakes of the characteris- 
tics of the decidua vera of norma] pregnancy, and is usually thrown off, 
either iu one complete east or in the shape of debris, about the time of 
the primary tubal rupture, and this event is frequently accompanied with 
metrorrhagia. The casting off of the decidua may precede, accompany, 
or follow the rupture. The persistence of life in the ovum after primary 
rupture does not prevent the shedding of this membrane. The decidua 
varies in thickness from one-eighth to one-quarter of an inch, is rough 
and shaggy upon its uterine side and smooth upon its inner surface, and, 
of course, in the uterus shows no traces of decidua reflexa and decidua 
serotina (Fig. 245). 

Fig. 245. 




Scrapings from the uterus in a case of ectopic gestation in the third month. 

a. Decidua vera. b. Decidua in the beginning of coagulation necrosis, showing many leucocytes. 

c. Blood sinus, d, d. Gland spaces. (Herzog.) 



Alterations and Changes in the Tube and Ovum. These vary 
greatly with the location of the gestation-sac, but swelling and turgescence 
are present in all cases from the beginning. This thickening consists at 
first in simple enlargement of the calibre of vessels due to the stimulus 
given by the existence of the pregnancy, then of hypertrophy of mus- 
cular fibre, the same as the first changes which take place in the uterus 
in normal pregnancy. Then follows the free development of connective 
tissue and often disappearance of muscular fibres, particularly following 
the evidences of minute rupture, which disintegrates and breaks them up 
by small extravasations and hemorrhages, and gives rise to inflammatory 



ECTOPIC GESTATION. 



361 



and cystic changes ; or pressure-atrophy of the wall takes place opposite 
the placental attachment, which has become the thickest part of the tube. 

Closure of the ostium abdominale usually takes place about the seventh 
or eighth week when the oosperm is retained in the middle or inner 
portion. When, however, it is retained near the abdominal opening, 
complete closure does not occur, and there is, consequently, a tendency 
to tubal abortion. 

In the apparent exceptions to this rule in which the ostium is not 
closed at twelve weeks, examination of the specimen and careful analysis 
of the history usually demonstrate that rupture had taken place several 
weeks earlier. 

Fig. 246. 




Section from gravid Fallopian tube. Lutz, Obj. 3 ; Eye-piece No. 3. 
A. Decidual cells. B. Villi. C. Syncytial buds cut transversely. D. Blood in intervillous space. 



The formation of a decidua in the pregnant tube is now conceded by 
all competent observers. A number of my own cases have been exam- 
ined for that purpose, and a decidua has invariably been found (Fig. 
246). It has also occasionally been found in the opposite non-pregnant 
tube. The amount of decidua vera, however, varies considerably in 
different cases, but in all instances the characteristics of the true decidua 
of uterine pregnancy are shown; namely, the usual two layers, a super- 
ficial compact, and a spongy, lower layer. The enlarged vessels common 



362 PATHOLOGY OF PREGNANCY. 

to the whole tube arc particularly prominent in that portion of the 
mucosa covered by decidua t<> which the ovum becomes attached, and 
which is known as decidua serotina, This decidua serotina grows more 
rapidly than the rest of the decidua. 

At an early period in uterine gestation an intervillous space filled with 

maternal blood, hounded on the outside throughout most of its extent by 

the decidua reflexa, surrounds the whole chorion. In tubal pregnancy, 

therefore, there must also always he formed a decidua reilexa, because ;:<i 
intervillous -pace capable of retaining the maternal blood can be formed 
only by a decidua reflexa, unless we assume that the tube very early 
becomes completely obliterated on both sides of the ovum. Since we 
have no proof at all of such a very improbable occurrence, a decidua 
reflexa becomes an absolute necessity for the establishment of the inter- 
villous space (Max Herzog). 

1 1 kmorrhages found in the tube are most frequently the result of rup- 
ture of the reflexal vessels. As pregnancy advances the decidual cells 
in the balance of the tube disappear, and inflammatory changes, the result 
of the minute ruptures, combined with possibly mild pre-existing septic 
conditions, change the general texture of the mass. The growth of the 
ovum stretches the lumen of the tube, which gradually becomes, together 
w r ith the placeuta and membraues, a part of the investing heterogeneous 
gestation-sac. 

But little can be said in this connection of the changes in the ovum, 
its development and attachment being made comparatively plain if the 
presence of a decidua is admitted, as it thus follows the transformations 
usual to a pregnancy in the uterus, subject simply to the changes incident 
to lack of space in the tubes, and the traumatisms which must almost 
inevitably result, and which will be considered when speaking of the 
different varieties. 

The true investing foetal membranes, namely, amnion and chorion, 
differ in no wise from the same structures in uterine pregnancy, but are 
subsequently also subject to the alterations incident to trauma and pos- 
sible sepsis. 

Tubal Mole and Tubal Abortion. The subject of alterations in the ovum 
can hardly be dismissed without reference to that arrest of development 
during the first few weeks which results in what is known as a tubal 
mole. An ovum during its first few weeks of growth, depending as it 
does for life upon very delicate chorionic villi lightly attached, is in great 
and constant danger of destruction. In some cases, by reason of chori- 
onic hemorrhage, the circulation is cut off, the ovum is partially or 
totally detached, remains in situ and is absorbed, or, after detachment, 
particularly when located in the outer third of the tube, it may be ex- 
pelled through a patent ostium abdominale into the abdominal cavity. 
This constitutes what is known as a tubal abortion. Sometimes, how- 
ever, the tube ruptures and the mole is extruded directly into the free 
cavity, often with most appalling symptoms. 

It cannot be stated definitely thai subperitoneal rupture does not occur 
in these early cases, for no observations bearing upon this point have, so 
far as the writer knows, been absolutely demonstrated. The proof of 
this condition must depend upon the report of a competent pathologist 
after thorough dissection. 



ECTOPIC GESTATION. 



363 



A Tubal Mole resembles a blood-clot in color and consistence, is 
round or ovoid, and from two to six centimetres in diameter (Fig. 
247). It usually presents, on section, a smooth- walled cavity, lined with 
amnion, occasionally containing foetal remnants. Both amniotic cavity 
and foetal remnants may be absent, but the presence of chorionic villi 
makes the origin manifest. Bland Sutton believes that a tubal mole 
" is due to blood extra vasated from the circulation of the embryo into 
the subchorionic chamber." 

Fig. 247. 




Tubal mole, fifth week. 
a. Mole partially extending from ruptured portion of tube. b. Ostium abdominale partially closed 

by infolding of tbe fimbriae. 

Changes in the Placenta. In no case of tubal pregnancy is there 
absence of decidual formation, but there is a marked difference in differ- 
ent cases as to the extent to which this membrane is formed. Observations 
by a number of modern competent observers, looking toward an eluci- 
dation of this question, demonstrate the almost constant presence of 
decidual membrane in the tube. Taking this for granted, the placenta, 
as in uterine pregnancy, is composed of loosely held masses of chorionic 
villi with intervillous blood-spaces bounded externally by varying areas 
of decidua serotina. The development of this organ is necessarily mod- 
ified by the amount of decidua present. When to this is added the nar- 
rowed available space still further constricted by the rugosities of the 
mucosa and the mobility of the tube, the difficulties in the way of the 
development and growth of the placenta can readily be appreciated. 

When, however, rupture occurs, and the torn walls of the tube spread 
out, if the ovum survive, the placenta forms further attachments to 
neighboring structures and continues its growth. The size of placentas 
varies directly with the vascularity of the structures upon which they 
become implanted and with the permanence of the attachment. From 
the beginning the essential elements of disturbance in the development 
of the placenta are traumatic hemorrhages. The tube wall early in preg- 
nancy cannot, as a rule, accommodate itself to the growing ovum. It 
becomes stretched, and ruptures take place into the substance of the 
serotina, accompanied by hemorrhage into the intervillous space, endan- 
gering the integrity of villi and chorion. 



;; ( ;i PATHOLOGY OF PREGNANCY. 

When an ectopic placenta is examined at any period of -rotation, 
evidences of previous hemorrhages arc rarely absent These hemor- 
rhages arc necessarily small while the mass is confined within the tube, 

l>nt after rupture they may he severe and even fatal. The fatal termi- 
nation is, however, ordinarily due to what may be termed u detachment 

hemorrhages" — that is, hemorrhages from maternal vessels consequent 
upon detachment of the placenta. 

Independent of detachment hemorrhages, however, are the constantly 
recurring extravasations into the serotinal tissue. These intraplacental 
hemorrhages materially increase the bulk of the placenta, and produce 
an apparent disproportion between its size and that of the ovum. This 
disproportion is the foundation for the erroneous statement that the 
growth of the placenta continues after the death of the ovum. It is 
very possible that an intraplacental hemorrhage may increase somewhat, 
but it is hardly reasonable to suppose that the formation of true placental 
tissue could continue, and this has never been demonstrated. The chori- 
onic villi degenerate and become in a very short time mere phantoms 
with indistinct outlines. New formation of villi is most improbable. 
The decidua serotina also undergoes rapid degeneration. Therefore, no 
real growth of placental tissue can occur after the death of the foetus; if 
an increase in size takes place it must be due to traumatic hemorrhages. 

The placenta is then transformed from an oval or round disk to a more 
or less globular mass, which, upon careful examination, is seen to be com- 
posed of blood-clots in various degrees of organization, with deteriorated 
villi interspersed, and a large number of leucocytes, and to contain no 
more than the normal amount of true placental tissue. In case of very 
old placentas, indeed, so marked an alteration has occurred that little 
normal placental tissue can be recognized. 

Symptomatology and Diagnosis. 

A. Prior to the Fourth Month. 

General Considerations. Prior to the fourth month the three cardinal 
and practically constant points in the diagnosis of beginning extra-uterine 
pregnancy are (1) disturbance of menstruation, (2) sharp pelvic pain, 
usually accompanied w r ith faintness, and (3) the presence of a mass 
adjacent to and connected with the uterus. Certainty of diagnosis is 
based upon a logical analysis of these three factors. 

1. Disturbance of Menstruation. Menstruation is almost always retarded ; 
but the variations as regards the amount, character, and periodicity of the 
hemorrhage are so numerous as to render the description of a typical case 
difficult. In some cases uterine hemorrhage occurs a day or two follow- 
ing the date of the expected menstruation; in other cases amenorrhoea 
persists throughout the pregnancy; the flow may continue for two or 
three days, and may recur with sufficient regularity to simulate menstru- 
ation, but this is exceptional. The first day of the flow is seldom or 
never the tw r enty-eighth day after the beginning of the last menstruation. 
Sometimes the flow continues for a clay or two, and then recurs at irreg- 
ular intervals; but in other cases the hemorrhage persists for weeks at a 
time. The amount of blood lost also varies greatly, from a mere show 



ECTOPIC GESTATION. 365 

to a severe hemorrhage. The blood usually contains small patches of 
mucosa or large, well-defined membranes, and occasionally a complete 
cast of the lining of the uterus. These hemorrhages, regular or irregular, 
occurring early in ectopic gestation, usually indicate shedding of the 
decidua. 

2. Pelvic Pain. The pain is usually of two kinds: the recurrent, con- 
tractile pain due to uterine contractions, and the sharp, tearing pain, 
accompanied with faintness, which indicates rupture to a greater or less 
degree. Excruciating pain with syncope usually points to serious rupture. 

3. Presence of a Mass. When the pregnancy is located in the middle 
or at the outer end of the normally situated tube, and is unruptured, a 
well-defined movable mass, contiguous to the uterus, can be felt. When 
the tube is prolapsed posteriorly, the mass will be felt posterior to the 
body of the uterus. After rupture into the broad ligament has taken 
place the mass can still be felt lateral to the uterus, but it is lower, not 
so well outlined, and less movable. When sepsis has supervened, the 
presence of exudate may render the outlining of the mass still more 
difficult. In interstitial pregnancy the mass appears as an irregular 
bulging at the corner of the uterus. When early rupture into the gen- 
eral peritoneal cavity has occurred, no mass may be felt at all. 

The nausea, changes in the breasts, and discoloration of the vaginal 
mucosa are confirmatory of the diagnosis of pregnancy, and, when com- 
bined with the signs detailed above, are strongly presumptive of extra- 
uterine pregnancy. Valuable corroborative evidence is furnished by the 
changes in the uterus, and by uterine hemorrhage when it occurs. The 
adjoining pregnancy stimulates the growth of the uterus, but not to 
the extent which obtains in uterine gestation of the same age. This dis- 
proportion in size becomes more marked as pregnancy progresses. Uter- 
ine hemorrhage frequently occurs before the third month of extra-uterine 
pregnancy, and is usually accompanied with the discharge of decidua, 
which, as mentioned before, is cast off either in shreds, in large patches, 
or as a complete cast of the uterine cavity. The absence of chorionic 
villi after careful search furnishes another link in the chain of evidence. 
At this stage of the investigation exploration of the cavity of the uterus 
is warrantable. When, after careful introduction of a sound into the 
uterine cavity, the uterus is adj udged empty, the diagnosis of early ectopic 
pregnancy is practically established. 

Primary Intraperitoneal Rupture — Hematocele. In the great majority 
of cases, gravid Fallopian tubes rupture prior to the fourth month. This 
is known as primary rupture, to distinguish it from subsequent ruptures 
which may occur in the same pregnancy. Primary rupture may be intra- 
or extraperitoneal. Experience demonstrates that primary intraperitoneal 
ruptures generally occur prior to the seventh week, and so frequently in 
the fifth or sixth week after the last menstruation that pregnancy is not 
suspected. As women with pre-existing pelvic disease are especially 
prone to extra-uterine pregnancy, menstrual irregularities easily escape 
attention. 

The diagnosis of primary intraperitoneal rupture prior to the seventh 
week is the diagnosis of intra-abdominal hemorrhage. The absence of 
marked disturbance of menstruation does not preclude the existence of 
early rupture. The failure to observe the discharge is not significant, 



366 /'I THOLOQ Y OF PBEQNANCY. 

for thi< may ooour simultaneously with the rupture, <>r may closely follow 
it. The physical signs are identical with those of intra-abdominal hem- 
orrhage. 
The failure to recognize a tumor near the uterus is not verv important. 

Thorough examination is difficult on account of the condition of the 
patient. Even when the intra-abdominal hemorrhage is enormous, the 

chief reliance must be placed upon the general conditions of shock and 
collapse, as the presence of blood can seldom be demonstrated by fluctua- 
tion, abdominal palpation, or bimanual examination. A symptom rarely 
absent, however, is exquisite general abdominal tenderness. The ovum 
may be so small as to produce no appreciable enlargement, or it may 
have been expelled into the general peritoneal cavity. 




Primary intraperitoneal rupture ; fifth week. Tube completely ruptured. 
a. Ovum still slightly adherent to its original site. 

The following case furnishes an excellent illustration of the symptoma- 
tology of primary intraperitoneal rupture. 

On September 15, 1894, Mrs. J. P. C. was seized with a severe pain 
in the abdomen, which she described as feeling " like something break- 
ing in her stomach." Simultaneously there was a gush of bright, pink- 
ish, watery fluid from the vagina, which flooded her thighs and saturated 
her clothing. She was seen by a physician at 1.30 p.m., and by another 
an hour later, and at 5.30 by the writer. At that time she was almost 
in articulo mortis, and absolutely pulseless and perfectly cold. The 
patient was thirty-three years of age, had been married twelve years, 
and had three children, aged, respectively, ten, five, and three years. 
She had never had a miscarriage, and, so far as she knew, had never had 
uterine disease of any kind. She was a woman of magnificent physical 
development, weighed 230 pounds, and was full of courage. She had 
always menstruated regularly; but for several years had flowed for six 
or seven days at a period. On August 12th, exactly five weeks previous, 
she menstruated regularly, and the flow continued for six days. On 
August 29th, without warning, she suddenly had a severe pain resem- 
bling a labor pain, which continued for ten minutes, and was accom- 
panied by nausea and vomiting. On August 31st, while travelling on 
the cars, this pain recurred and lasted half an hour. While away from 
home she had two or three short, severe pains and a slight diarrhoea. 



ECTOPIC GESTATION. 367 

On September 9th, after her return home, she began to menstruate 
exactly on time, but the flow was checked by a sudden fright, her son 
being seized with convulsions in her presence. The same evening she 
had another short, acute attack of abdominal colic. The menstrual flow 
returned the next day, but ceased after a few hours. It again returned, 
but ceased two days before the final attack. 

When first seen by the writer it was evident from the profound col- 
lapse, indicated by the total absence of radial pulse, and the excessive 
pallor and death-like coldness of the body, that the patient was suffer- 
ing from internal hemorrhage; while the dyspnoea made it plain that 
the time for action was short, and that if something was not immedi- 
ately done it would be too late. Further physical examination revealed 
nothing more than local tenderness over the whole abdomen. Sudden 
pressure would elicit repeated expressions of pain. 

A careful and thorough vaginal examination was made, which was 
entirely negative. The fact that she was flowing at the time, of course 
directed my attention to the pelvic organs as the probable source of 
hemorrhage, and the information obtained from the patient's friends 
and from herself, regarding the previous attacks of pelvic pain, made 
the diagnosis of ruptured tubal pregnancy more than probable. Two 
objects were therefore kept in mind in making the examination. First, 
the determination of the presence of free blood in the abdominal cavity, 
and, second, the discovery of a mass to one or the other side of the 
uterus. The examination failed, however, in both respects; repeated 
percussion over the abdomen absolutely failed to give any impulse or 
sense of fluctuation, either upon deep digital pressure into Douglas's 
pouch or at either side of the uterus, and no enlargement of the Fallo- 
pian tubes could be detected. The thickness of the abdominal walls in 
this patient greatly increased the difficulty of and embarrassed the ex- 
amination. 

The correctness of the diagnosis became evident even before the peri- 
toneum was incised. After the incision w^as made and the intestines 
pushed back, the blood surged out over the surroundings. A careful 
estimate of the amount of blood in the abdomen would place it at not 
less than eighty ounces. The right Fallopian tube was found to be 
widely ruptured at its middle and the ovum embraced by the gaping; 
edges of the wound (Fig. 247). The lumen of the tube was perfect ex- 
cepting at the seat of rupture. 

The fimbriae were partially drawn into the abdominal ostium. There 
was a great attenuation of the tubal wall at the location of the tear, 
which occurred at a point opposite to the seat of attachment of the ovum. 

Primary Extraperitoneal Rupture — Haematoma of the Broad Ligament. 
An extra-uterine pregnancy, instead of developing in the direction of the 
free abdominal cavity, may grow downward and cleave the folds of the 
broad ligament without rupture of the tube proper, the adjoining portions 
of the broad ligament stretching gradually to accommodate the growing 
ovum. As a rule, rupture occurs between the seventh and twelfth week 
of pregnancy. 

Here we have, first, the usual signs of extra-uterine pregnancy, together 
with the constant presence of a mass contiguous to and connected with 
the uterus. Rupture is indicated by an increase in pain and faintness. 



368 FATlloi.ocv of PKF.<; \AXCY. 

The Bigns before this accident arc often not sufficiently marked to denote 
the character of the pregnancy, and, as a rule, the patient believes her- 
sclf pregnant in the normal way, Whereas, in the early primary intra- 
abdominal rupture faintness and syncope are the m<»t striking symptoms, 
and the pain not so severe, in this variety severe pain is usual, while 
the collapse is not bo extreme. The pain in most cases is recurrent and 
paroxysmal, coming on without warning and usually soon passing away, 
to be followed by another series of paroxysms a few hours or a few days 
later, each attack probably indicating an extension of the rupture. As 
the blood effused is limited by the resistance of the adjoining structures, 
we do not witness those appalling symptoms common to the already men- 
tioned intraperitoneal ruptures. 

To make the picture plain regarding these cases, if a woman of child- 
bearing age suddenly complains of severe pelvic pains, accompanied by 
nausea and faintness; if, on investigation, she says that she has missed 
one, two, or three menstrual periods, or has flowed in a very irregu- 
lar manner, and thinks herself pregnant; if she has the usual vulvar 
and vaginal discolorations common to pregnancy and the changes in the 
breasts, with nausea, and if these attacks of pain and faintness recur, 
extra- uterine pregnancy must be strongly suspected. If, on examination, 
the uterus is found enlarged, but not to a sufficient degree to correspond 
to a pregnancy of that age, while immediately adjoining the uterus and 
continuous with it a tense and vaguely fluctuating enlargement is discov- 
ered, then ectopic gestation, ruptured extraperitoneally, is a reasonable 
conclusion, and the case may be so regarded and treated. The signs 
mentioned may not all be present, and many cases are sufficiently ob- 
scure to bring doubt, but to the experienced surgeon there are usually 
landmarks enough to outline the course to pursue. 

Early cases of this kind undoubtedly occur which are not diagnosed, 
the ovum and secundines being gradually absorbed and the patient never 
being very ill; but when the accident takes place after the seventh week 
severe illness generally ensues. Even at ten and twelve weeks the rupture 
may have proceeded so evenly and slowly that the patient may not seek 
medical advice until constitutional symptoms indicative of sepsis appear. 

In the very great majority of cases the ovum dies at the time of the 
rupture, and no further growth occurs. The traumatism existing, how- 
ever, leads to the formation of protective exudate, which very materially 
increases the size of the whole mass. This increase in size gives rise to 
more pronounced pain, and sooner or later, in almost all cases, sepsis 
supervenes and the mass breaks down into a suppurative focus, while 
the patient develops fever, sw-eats, chills, and the usual constitutional 
evidences of retained septic material. 

In patients seen for the first time in this condition, the diagnosis is 
often difficult, and in some, where the history is not very typical, is even 
impossible, as the signs differ little from those of the common forms of 
septic pelvic invasion. Careful inquiry into the history is the best reli- 
ance for avoiding mistakes. 

Secondary Ruptures. This term applies only to the last-named variety, 
namely, the extraperitoneal variety, where the ovum, after forcing its way 
below the peritoneum in the folds of the broad ligament, ruptures into 
the general peritoneal cavity. These secondary ruptures may occur from 



ECTOPIC GESTATION. 369 

different causes. After the primary rupture the ovum may survive, and 
its continued growth almost invariably results in communication with 
the general cavity. This variety of secondary rupture is sometimes 
sudden, and the effusion of blood into the general cavity may be so exten- 
sive as to give rise to the most serious symptoms with fatal results. The 
appearances are very similar to those of primary rupture of early date, 
and the treatment must be equally prompt. A secondary rupture may 
follow a primary rupture so closely that they can hardly be differentiated. 

In other cases, however, the ovum surviving, the secondary rupture 
may be slow and not extensive, the opening reinforced by quickly formed 
exudate and the symptoms more subdued. Such accidents may occur 
time and time again, and, if the ovum is not destroyed, there develops 
that class of so-called advanced, abdominal, extra-uterine pregnancy 
which will hereafter be described. 

When the ovum is destroyed by the primary rupture, secondary rup- 
tures may still occur. If the first rupture has so separated the ligamen- 
tous folds that only a thin peritoneal membrane is interposed between 
the mass and the general cavity, blood -pressure alone from recurrent 
hemorrhages may complete the rupture; or, the whole mass including its 
peritoneal covering becoming macerated and softened by sepsis, second- 
ary rupture may result' from lack of consistency. 

The interstitial or tubo-uterine and infundibular or tubo-ovarian vari- 
eties of ectopic gestation are especially prone to early primary intraperi- 
toneal rupture. In the true tubal variety, if the placenta is implanted 
on the superior inner surface of the tube, extraperitoneal rupture is more 
likely to occur; if, on the contrary, it is implanted on the lower inner 
surface, the upper part of the tube thins out, and early rupture into the 
general peritoneal cavity is most probable. Almost all the extraperi- 
toneal ruptured cases belong to the true tubal variety. 

B. After the Fourth Month. 

Unruptured Tubal Pregnancy. When the ovum survives all the dangers 
which threaten its existence, new signs become evident after the fourth 
month which demand separate consideration in their relation to diagnosis. 
Few ectopic gestations survive the fourth month, and very few, indeed, of 
these have not been subject to more or less rupture, either intra- or extra- 
peritoneal. Most of the reports of examinations of extra-uterine cases are 
not sufficiently minute and explicit to base a positive opinion upon; but, 
nevertheless, there can be no doubt that women have passed through 
extra-uterine pregnancy to term, carrying the child within the enlarged 
dilated tube, without appreciable rupture in any direction. Many of the 
reported cases of this variety have, however, been shown to have previ- 
ously ruptured slowly below, between the folds of the broad ligament. 

Abdominal Pregnancies Without Rupture. The space at command will 
not admit of reviewing the discussion whether such a condition can 
exist. Suffice it to say that advocates of that theory believe that an 
impregnated ovum can find its way into the general cavity or that an 
ovule can there become impregnated and implanted, and grow even to 
full term without rupture. Their opponents stoutly maintain that all 
so-called abdominal pregnancies were originally tubal, that rupture took 

24 



370 PATHOLOGY OF PREGNANCY. 

place into the general abdominal cavity, but thai sufficient attachment to 
the tubal mucous membrane remained to nourish the ovum, and that 

eventually, although the placenta became universally attached to sur- 
rounding structures, all cases that were examined with sufficient care by 
competent authorities could always be traced to the tube as the original 
site of primary implantation. The consensus of opinion at this date 
inclines to the latter view. 

PIG. 249. 




Unruptured tubal pregnancy three weeks after spurious labor. 
a. Obliterated vaginal fornix. 



In almost all cases of advanced ectopic gestation we have the symp- 
toms and signs common to uterine and ectopic gestation, namely: 

Disturbance of menstruation; 

Changes in the breasts; 

Enlargement of the uterus; 

Nausea ; 

Changes of the vulva; 

Thinning out and softening of the lower uterine segment; 

Mucous vaginal discharges; 
as well as the symptoms heretofore described as resulting from rupture 
of greater or less extent in the earlier months. 

As the gestation advances beyond the fourth month the other signs 
which become manifest demand special consideration. Of these the 
principal are: (1) changes in the breasts characteristic of advanced preg- 
nancy; (2) movements of the foetus; and (3) abdominal enlargement; 
while careful examination often reveals (4) ballottement; and (5) pla- 
cental souffle. 

1. Changes in the Breasts. These are practically similar to the changes 
which occur in uterine pregnancy, but are generally not so well marked; 
the areola is not so well defined, the breast not so full, nor the secretion 
so abundant. 



ECTOPIC GESTATION. 



371 



2. Movements of the Foetus. The perceptibility of these movemeDts 
ditfers according to the variety of the case. When dealing with a case 
of so-called abdominal pregnancy, the result of secondary rupture into 
the free peritoneal cavity, if the patient is reasonably thin, the move- 
ments are often extremely plain to the examiner, even when hardly 
noticeable to the patient. When near term and the child is reasonably 
vigorous, the movements may be felt and seen so plainly immediately 
beneath the abdominal wall as to form a valuable diagnostic sign. In 
the subperitoneal forms the movements are not so plain, but may be very 
painful to the patient, although they closely resemble those of the foetus 
in utero. Generally speaking, if the pregnancy advances to the fifth 
month, the movements of the foetus are thereafter more plainly discerni- 
ble than are those of a uterine pregnancy of the same age. 

Fig. 250. 




Secondary abdominal pregnancy at eight months, primarily tubal. 



3. Abdominal Enlargement. Proper and painstaking observation of the 
abdominal enlargement of a woman supposed to be with child extra- 
uterum is a matter of the very greatest importance. While the ovum 
is small and the mass containing it is buried in the pelvis, the abdomen 



372 ''•« THOLOQ Y OF PBEQNANCY. 

is, of course, do! enlarged. When the enlargement becomes discernible, 
it differs according to the variety of the case. In general, it may be 
said thai it differs materially from normal gestation in thai it is not so 
symmetrica] nor is it, at fust, so centrally situated. If the patient is the 
victim of an interstitial pregnancy it may show very soon after the third 
month, usually slightly to one side, [f the gestation is free tubal and 
subperitoneal the enlargement will usually show first on the side affected, 
generally resonant from superimposed intestines and more or less irregu- 
lar and nodular; while if abdominal it will he still more irregular and 
nodular, the mass plainly recognizable, and unless adhesions have formed 
to the intestine it will be dull on percussion. The mass is often wider 
from side to side and differs essentially from the smooth ovoid of the 
normally pregnant uterus. 

Bimanual examination, rectal and vaginal, of a six to seven months' 
ectopic gestation will for the experienced examiner throw much light 
upon the nature of the case. The uterus at this stage can usually be 
outlined, and a well-marked groove between the uterus and sac can often 
be made out. Great care must be taken, however, in reaching a definite 
conclusion : A pregnant retroflexed uterus in some cases is most decep- 
tive, while an advanced unruptured true tubal or interstitial pregnancy 
may be so intimately blended with the uterus as to make the outlining 
of that organ well-nigh impossible. In true tubal unruptured pregnancy 
a sigu of importance is the obliteration of the vaginal fornix on the 
affected side. See Fig. 249. 

In cases where there have been repeated ruptures with hemorrhages 
surrounded by exudate, the diagnosis is sometimes very difficult, the 
abdomen and pelvis being filled with irregular masses varying in size 
from small nodules to lumps the size of a fist, and the whole matted 
together by adhesions. The uterus is adherent to these masses, fused 
among them, and often indistinguishable from them. 

The foetus itself may be palpated sometimes with the very greatest 
ease, and the extreme thinness of the tissues between the overlying hand 
and the foetus is often quite a characteristic sign. Palpation of both foetus 
and uterus is frequently rendered difficult, however, by the implantation 
of the placenta upon the anterior wall of the sac. 

If the sac is interstitial it may still retain its central location, but its 
length will be out of proportion to its breadth. If tubal, the uterus will 
usually be pushed to one side, and almost always be crowded up behind 
the pubes, as in the majority of cases the sac settles down in Douglas' 
pouch. If the pregnancy develops very low down, and if adhesions do 
not form, the uterus may be so crowded up that the cervix can hardly be 
reached. The size of the organ does not correspond to the age of the 
suspected pregnancy, varying, when the case is at term, from four to six 
inches in depth. In some women examined at this time, the nature of the 
case is most apparent, the important item of diagnosis being the outlining 
of the uterus proper and the determination of its location as independent 
of the sac. 

4. Ballottement may be elicited either anteriorly or posteriorly to the 
uterus. 

5. Placental Souffle. This sign, common to normal as well as to extra- 
uterine pregnancy, is of significance only in a small proportion of cases. 



ECTOPIC GESTATION. 373 

It begins to be heard about the end of the third month, but is often very 
faint. In secondary abdominal ruptures, when the placenta spreads out 
anteriorly just beneath the abdominal wall, it may prove a valuable sign, 
as it is then extremely loud, is sometimes spread over almost the entire 
abdomen, and by its intensity, suggests the character of the case. 

General Conclusions Concerning Signs and Diagnosis. From a perusal of 
the foregoing remarks on the signs of ectopic gestatiou it becomes evi- 
dent that the existing variations are misleading by reason of their great 
diversity, and yet the diagnosis, after a time has elapsed, is not usually 
attended with as much difficulty as might be inferred. 

Diagnosis is well-nigh impossible in patients who come under observa- 
tion early in pregnancy and before any degree of rupture has occurred. 
There are then present evidences of pregnancy and a mass adjacent to 
and, moreover, connected with the uterus. If such a patient has been 
carefully examined within four or five months, or just before the begin- 
ning of the ectopic gestation, and no mass found, the recent appearance 
of the latter becomes extremely significant. If no such opportunity has 
been offered, however, there is often little, if anything, to differentiate 
between the gestation sac and a possible cystic enlarged ovary, a dermoid 
cyst, or any condition characterized by such an enlargement and not 
inconsistent with pregnancy. 

One can seldom be certain in this class of cases. Beside the signs of 
pregnancy and the presence of the enlargement alluded to, it can only be 
mentioned as an aid in diagnosis that there is usually more pain, which 
the patient describes as griping or colicky, coming on sharply and 
leaving suddenly, to be soon repeated, usually lasting from a few hours 
to a day or two, and followed, it may be, by a respite for a few days, 
when another series of pains occurs. The lump felt near the uterus may 
also be said to be rather soft and possibly slightly fluctuating; it is gen- 
erally unattached and movable and throbbing because of enlarged vessels. 

If hemorrhage occurs from the uterus, however, very great assistance 
is derived from a microscopical examination of the discharge, as by this 
is often revealed the presence of decidual cells and the absence of chori- 
onic villi. 

When primary rupture into the abdomen occurs very early, say from 
the fourth to the eighth week, the hemorrhage in the abdominal cavity 
is usually large, and these cases present a most striking and almost un- 
mistakable picture. 

Subperitoneal ruptures take place from the seventh to the twelfth 
week of pregnancy. Before rupture the paroxysms of pain are more 
frequent and the pains more severe, and the shock resulting from the 
rupture is not so great. Examination at this time reveals a large semi- 
fluctuating mass filling one side of the pelvis, more or less obliterating 
the vaginal sulcus on that side, with a broad base and so intimately 
blended with the uterus as to make the outlining of the latter difficult. 

In secondary ruptures in the peritoneal cavity we find the symptoms 
just described under subperitoneal rupture, followed by those which 
belong to primary ruptures. 

The symptoms of advanced ectopic gestation are the symptoms of 
advanced pregnancy with infinitely more general abdominal disturbance 
than is usually found in uterine pregnancy of the same age. These dis- 



37 \ Pi VHOLOQY OF PREGNANCY, 

turbaDCefi arc due not only to the conditions already described, hut to 

innumerable, accidental, coexisting complications. 

In the subperitoneal variety displacemenl of contiguous organs must 
Deo ssarily occur. The bladder, uterus, rectum, ureters, and kidneys are 
always more or less displaced or compressed, with resultant disturbance of 
function. I fence we frequently observe dysuria, indigestion, and consti- 
pation, even to the point of obstruction, or it may be hydronephrosis or 
nephritis, with or without eclampsia, and excessive oedema from compres- 
sion of the vessels. 

Peritonitis, which is a constant complh ation, is especially severe in the 
abdominal variety. Whereas, fatal general peritonitis is sometimes set 
up by the rupture of an early tubal pregnancy, in advanced pregnancy 
it usually assumes a more chronic type, producing great alteration in the 
sac-wall and universal adhesions, so much so that the relations of the 
various structures are recognized with difficulty. 

Hemorrhage is also very common, not the excessive hemorrhage into 
the peritoneal cavity which occurs in early pregnancy, but repeated, 
-mail hemorrhages circumscribed by surrounding adhesions. 

Pain is the dominant symptom in the vast majority of cases of advanced 
ectopic gestation with or without rupture. A few cases have, however, 
been observed in which a child has been carried to term extra-uterum 
without excessive pain. These were probably cases of unruptured true 
tubal pregnancy, and are extremely rare. Pain is the natural result of 
the visceral displacement, of the repeated hemorrhages, of the pressure 
upou nerves, and of the peritonitis. The pain which many women suffer 
in the later months of ectopic gestation is agonizing. 

False or Spurious Labor. Whenthe foetus has reached term, spurious 
or false labor supervenes. It may, however, occur earlier, at the seventh 
or eighth month. This peculiar phenomenon has attracted much atten- 
tion and given rise to many conjectures, but no very satisfactory explana- 
tion of its occurrence has been advanced. It differs materially in different 
patients, being sometimes abrupt, well marked, and consisting of denned 
contractile pains, gradually increasing in severity and lasting from a few 
hours to one or two days, and after reaching a certain degree of intensity 
gradually subsiding, it may be, never to return. In other patients it 
recurs a number of times several days apart, so that a woman may have 
had a number of so-called spurious labors. There is really but one true 
labor, and that follows or rather causes the death of the child. Pains 
recurring later are probably due to inflammatory changes in the gestation 
sac or to some complication. In some patients the movements of the 
foetus become gradually fainter, and the signs of active living pregnancy 
subside without the occurrence of false labor. 

Often during such labor the movements of the child become excessively 
active; when the climax of pain is reached all movements suddenly cease 
and the pains gradually subside. 

Accompanying these labor pains there is usually hemorrhage from the 
uterus, sometimes very slight, at other times very profuse, and if decidual 
membrane remains it is generally expelled. Are these pains caused 
by contractions in the uterus or in the gestation-sac? The changes 
that take place in the uterus, the expulsion of membrane in some cases, 
the almost constant occurrence of hemorrhage, indicate that in all cases 



ECTOPIC GESTATION. 375 

the uterus contracts, but it seems almost impossible for notable contrac- 
tion to occur in the wall of a gestation-sac, often hardly thicker than 
parchment, and which possesses almost no muscular tissue. Probably 
contractions in the sac proper occur only in the subperitoneal, true tubal 
and interstitial varieties, where the sac wall still contains a good deal of 
muscular tissue. 

Changes After Spurious Labor. Well-defined spurious labor always 
results in death of the foetus; following this there is subsidence of the 
abdominal swelling, and involution of the uterus, accompanied by mod- 
erate lochial discharge resembling that of uterine pregnancy, but not 
so profuse. The placental souffle gradually disappears, being seldom 
noticeable after two or three weeks. The breasts may discharge milk for 
a few days. Well-marked and immediate decrease in the size of the 
abdomen is not always constant, sometimes because of delay in absorp- 
tion of the liquor amnii or because of increase in the placental bulk 
caused by hemorrhage from vessels ruptured during the spurious labor 
or disintegrated by septic changes. 

Sometimes following spurious labor septic symptoms appear, hectic 
fever develops, and the whole gestation-sac breaks down into a sup- 
purative gangrenous mass. The pus burrows in various directions, 
almost always finding its way into some adjoining organ or through 
the abdominal wall, whence it is expelled, the disintegrated remains 
of the foetus following the same channel. Numerous cases of gradual 
expulsion of the different parts of foetuses by way of the bladder, rec- 
tum, vagina, or abdominal wall are recorded in the literature. Very 
few, if any, advanced cases are mentioned as opening into the general 
peritoneal cavity and proving fatal by rapid septic peritonitis, because 
when the gestation-sac reaches certain dimensions the pressure and in- 
flammatory changes obliterate the general cavity and all the neighbor- 
ing organs become intimately adherent to the outer surface of the sac so 
that there is no free cavity for the pus to break into. This process of 
maceration, suppuration, and expulsion, however, is usually fraught with 
infinite pain and imminent danger to the unfortunate victims, many of 
whom die exhausted by hectic fever. 

In a reasonable proportion of these cases the foetus and its investing 
membranes and placenta undergo peculiar and interesting changes with- 
out septic symptoms, these changes resulting in the abdominal inclusion 
of the modified foetus, now styled lithopedion. This term is supposed to 
apply only to calcified foetuses, but is generally used to signify a foetus 
retained for a long time without putrefaction and suppuration. 

The changes may result in mummification, or calcification, or adipocere 
formation of the ovum, or the sac, or both, the same specimen frequently 
showing the various formations in different locations. 

Mummification seems to result from absorption of all the fluid por- 
tions of the foetus, and it may be of the sac and placenta, the hard bones 
remaining more or less intact, and the soft parts having the appearance 
of dark-brown, shrunken parchment. 

Calcification means hardening of all the parts from impregnation 
with lime salts. 

Adipocere formation refers to that condition in which the soft 
parts of the foetus and even portions of the bone are converted into a 



376 PATHOLOGY OF PREQNAXCY. 

soft soapy mass, supposed to be duo to a combination of the fats and 
ammonia. 

A total sic which has undergone these changes may remain /'// situ for 
an indefinite Dumber of years. It is reported that many of them have 
been carried without harm for thirty, forty, and even fifty years, being 
then demonstrated post mortem. At any time, however, even after many 

year-, without apparent cause, infection of the sir may occur, attended 

with all the dangers described as resulting from primary septic infection, 
such as happens immediately after spurious labor. 

Treatment. 

1. Prior to the Fourth Month. 

General Considerations. Surgery offers the only treatment of value in 
ectopic gestation prior to the fourth month. In exceptional cases opera- 
tion is not advisable : 

When the patient is moribund, operation is useless. 

When the patient is recovering, watchful expectancy may be all that is 
necessary. A blighted ovum can unquestionably be absorbed. The 
patient may not come under observation until recovery is well under 
way. If a mass, the character of which is undoubted, is painless on 
palpation, is known to be decreasing in size, and is becoming firmer in 
consistency, and if the patient presents no symptoms, under such circum- 
stances operation would be meddlesome interference. 

When the diagnosis is obscure. The ovum may be expelled through 
a patent ostium abdominale into the general' peritoneal cavity, and be 
there absorbed, or it may perish and be absorbed in situ, or intra- or sub- 
peritoneal rupture may take place and the symptoms not be sufficiently 
marked or severe to establish a diagnosis or to demand exploratory 
incision. 

Morphine injections into the gestation-sac or the passing of a strong 
electric current through it, with or without puncture, are measures which 
were much in vogue in former years, the rationale of such measures 
being the destruction of the life of the foetus, trusting to nature to absorb 
the products of conception. Experience has proved beyond doubt the 
inferiority of these methods of treatment. It is often impossible to deter- 
mine whether the foetus is alive or dead, and its death, in the majority of 
instances, is not followed by absorption with cure of the patient. The 
employment of these measures does not make the diagnosis clear when 
there is doubt, and, beyond all, the manipulation and interference inci- 
dent to their thorough application have proved at least as dangerous as 
operation. 

In no department of surgery have the results been more brilliant, 
more perfect, and more life-saving than in the modern surgery of early 
ectopic gestation. 

(a) Before Rupture. 

Unless one of the above-noted exceptional conditions exists, unruptured 
ectopic pregnancy prior to the fourth month should always be removed. 
This is usually best accomplished by median abdominal section with 



ECTOPIC GESTATION. 377 

removal of the affected tube and its contents. The operation is ex- 
tremely simple, as adhesions are not usually present. A ligature is placed 
on either side of the mass, and the latter excised completely, bleeding 
points being caught and, if necessary, ligated. The cut surfaces are 
brought together by means of catgut sutures, thereby maintaining the 
function of the broad ligament in supporting the uterus in position, and 
another overhand continued suture, to cover traumatism and sutures with 
peritoneum, thereby preventing adhesions, adds to the safety of the 
patient. Although we usually employ catgut, the objections to silk are 
not of importance, for no septic focus is encountered, and if the opera- 
tion be properly performed, without the introduction of sepsis, the con- 
valescence will be rapid and without complications. 

When the pregnancy is of the interstitial variety an incision is made 
through the muscular layers down to the sac, which is then shelled out 
carefully, the bleeding being checked by one or two layers of buried 
sutures, care being taken to cover the seat of operation with peritoneum 
by fine superficial sutures. In these cases it is particularly important 
not to close the abdominal cavity until all oozing has ceased. 

(b) After Rupture. 

1. Primary Intraperitoneal Rupture. In speaking of the symptomatol- 
ogy of this phase of ectopic gestation the statement was made that " The 
diagnosis of intraperitoneal rupture is the diagnosis of intra-abdominal 
hemorrhage, and the physical signs are identical." It may now be 
added that the treatment is that of intra-abdominal hemorrhage. The 
responsibility in some of these cases is immense; but the operator must 
not hesitate. Such patients frequently die in a few hours. The abdo- 
men must be opened and the bleeding point ligated. The symptoms are 
usually very acute and the hemorrhage most abundant. After the diag- 
nosis is established, the operation should be performed even if the patient 
has rallied, for the next hour may witness a new and, this time, fatal 
hemorrhage. Such patients are never safe, for they bleed repeatedly, and 
there is a gratifying uniformity of success following all these operations 
when the patient is not moribund. 

Acute Early Primary Ruptures with Free Abdominal Hemorrhage Should 
Always be Operated by the Abdominal Route. A woman suddenly faints, 
immediately receives competent medical assistance, but notwithstanding 
all treatment, in an hour or two is in profound collapse with the clinical 
signs of early primary rapture of ectopic gestation. This is a typical 
fulminant case, and the patient is bleeding to death. Abdominal section 
should forthwith be made and direct ligation applied. Fill the bowel 
with normal salt solution; place the patient in the Trendelenburg position, 
on the bed, if need be; thoroughly cleanse the field of operation; open 
quickly; dip the hand at once through the blood down to the point of 
rupture; place a clamp on each side of the rent; wipe away sufficient 
blood to enable ligatures to be passed; sweep the open hand a few times 
around the abdomen and remove the large clots and possibly the product 
of conception; exsect the tube; make sure of the hsernostasis and imme- 
diately close. The hemorrhage from the bleeding point can often be 
controlled in four or five minutes, and the operation completed in fifteen. 



378 PATHOLOGY OF PREGNANCY, 

During all this time, if necessary, continuous infusion of* physiological 
saline solution into the cellular tissue is being made by an assistant. 
I f during the operation septic material is encountered in the abdominal 

Cavity, be it exudate around the affected tube or disease of the Other tube, 

or doubtful conditions in the region of the appendix, or if the operator 

i- not reasonably certain of the aseptic character of hi- manipulations, 
then, if the patient's condition permit, the abdominal cavity should be 

thoroughly cleansed, after which drainage would better be employed 
through the lower end of the wound or through the vagina. If, how- 
ever, the patient's strength will not allow such prolongation of the opera- 
tion, time may be saved by the introduction of a large Mikulicz drain. 

In arriving at a proper conclusion whether or not in a case of this 
variety the patient will still be able to bear operation, a symptom of 
considerable importance is the presence of great restlessness, as it fre- 
quently means impending death, and, therefore, might directly contra- 
indicate interference. 2so matter how profound the shock, a patient is 
very seldom beyond hope of safety by rapid operation if she does not 
exhibit this restlessness. 

Discrimination should be employed, if possible, in differentiating 
between recurrent temporary swoons and profound progressive collapse, 
and it should be remembered that the shorter the time between the begin- 
ning of the attack and profound collapse the more urgent the need of 
immediate operation. 

Blood is left free in the abdominal cavity when the conditions of asep- 
sis are supposedly maintained, because the shorter the operation the better 
the prospective recovery; the less the manipulations, the less the absorp- 
tive powers of the peritoneum are impaired, and because the absorption 
into the circulation of the serum left in the cavity begins at once and 
stimulates the patient pending the general revival of vital forces. 

The Trendelenburg position is advised because the presence of large 
quantities of blood in the pelvis frequently interferes materially with 
the proper application of ligatures; because inversion of the patient 
causes gravitation of much of this blood toward the diaphragmatic region, 
where it is more easily absorbed, and because this position lessens the 
syncope. 

In the primary intraperitoneal rupture of interstitial pregnancy the 
treatment is exactly the same as that just described, for the symptoms 
are, if possible, more acute, except that it is not always necessary to 
exsect the tube, as the cavity which is left after complete removal of the 
ovum is closed by successive layers of sutures. If the gestation has 
materially advanced before rupture occurs, the traumatism inflicted upon 
the uterus may be so serious as to necessitate hysterectomy. 

2. Subperitoneal Ruptures. Subject to the exceptions noted under the head 
of general considerations, removal of the offending gestation-sac is the 
proper treatment for the cure of patients affected with subperitoneal rup- 
ture. As the hemorrhage in these cases, however, is restricted by the 
surrounding structures, the symptoms are less acute and alarming, and 
the shock not so great, although the pain is often much more severe. 

Although there is no doubt that many of these cases would recover by 
the unaided efforts of nature without operation, the latter is much to be 
preferred when the patient is seen soon after the rupture, because it elim- 



ECTOPIC GESTATION. 379 

inates many possible dangers, usually saves the patient much pain, and 
in the great majority of instances, results in recovery with complete and 
perfect physiological functions. When the patient does not come under 
observation until a considerable time has elapsed since the rupture, either 
she is convalescent or is suffering from complications, the treatment of 
which will presently be described. 

Acute non-septic subperitoneal rupture should always be treated by 
median abdominal section. Especial care should be taken in opening the 
abdominal cavity when, as frequently happens, the rupture does not occur 
until the tenth to the fourteenth week, for adhesions may be present and 
the contents of the sac be septic. The Trendelenburg position materially 
facilitates the operation. After the abdomen is opened the first step, and 
one of great importance, is carefully to wall off the affected area with 
pads of aseptic gauze so as thoroughly to protect the healthy portion of 
the cavity and its contents. If fluctuation is evident in a portion of the 
mass, a very small incision is made to open this part first, or a trocar may 
be introduced, and the liquid contents caused to flow out slowly, being 
caught on large gauze sponges. The whole mass is then shelled out of 
its bed and the vessels ligated. In some easily accessible cases the ves- 
sels may be ligated first. Almost the only source of danger lies in the 
loosening of intestinal adhesions. Occasionally the hemorrhage is very 
free, and a Mikulicz pelvic tamponade becomes advisable. 

3. Secondary Ruptures. The treatment of secondary ruptures is similar 
to that of the primary intraperitoneal form. The most important item 
to be kept in mind is the liability of the contents of the sac to be septic; 
therefore, the patient should not be placed in the Trendelenburg position 
until the abdomen is opened, the parts, if possible, well isolated, and the 
peritoneal cavity cleansed to the extent that the condition of the patient 
will allow. 

Septic Cases and the Vaginal Incision. When a patient has 
passed safely through the first stage of rupture without operation, she 
may, and very frequently does, suffer from various complications, all of 
which are the results of sepsis. The woman with primary or secondary 
intraperitoneal rupture may die in a few days from general diffuse peri- 
tonitis. As soon as such a condition is recognized an abdominal in- 
cision should be made, the cavity carefully mopped out or irrigated with 
warm normal salt solution, if it seems impossible to cleanse it properly 
with gauze, after which a large drain may be left protruding through the 
lower angle of the abdominal wound, or through an opening made into 
the posterior vaginal cul-de-sac, or both. These extremely dangerous 
cases are, fortunately, rare. 

Generally the sepsis is local, involving at first only the gestation-sac 
and the affected tube and the blood-clots resulting from the hemorrhage 
at the time of rupture. Exudate protects the general peritoneal cavity. 
If suppuration follows, adjoining organs may become involved, and pelvic 
abscess, with all its possible destructive lesions, result. With a milder 
form of sepsis suppuration may not occur, but fibrino-plastic exudate may 
eventually bind together all the affected parts and the adjoining organs 
in a conglomerate mass, giving rise to innumerable functional disturb- 
ances. 

In all these septic cases, if the mass is situated well down in the pelvis, 



380 PATHOLOGY OF PREGNANCY. 



vaginal incision with drainage is frequently the most desirable operation 
and is followed by the happiest results. The danger of hemorrhage 
usually disappears when septic conditions become manifest, because the 
vessels are occluded or much lessened in calibre. 

A wide incision is made through the posterior vagina] fornix, the mass 
thoroughly penetrated and broken up, and most of the debris removed. 
Abscess cavities are opened and drained, and adhesions thoroughly sepa- 
rated. Drainage, preferably with gauze, completes the operation. 

If such an operation is skilfully performed it is safer and shorter than 
by way of the abdomen, avoids the abdominal wound with its scar and 
tendency to hernia, and seldom fails to cure the patient. A suppurating 
hematocele or a phlegmon of the broad ligament resulting from a very 
early rupture may consist simply of a single cavity. Drainage may be 
established through a small opening posterior to the uterus, and, although 
the procedure is so slight as scarcely to deserve the title of operation, the 
result may be ideal. 

The precautions essential to success in these vaginal incisions may be 
mentioned briefly as follows : 

1. Make sure that the incision is sufficiently large to permit thorough 
drainage. 

2. Make certain that no septic focus remains unexplored. A proper 
knowledge of the anatomy of the parts involved and reasonable tactile 
sense will enable the operator to avoid injury to important structures. 
In most instances it is less dangerous to open the free cavity and dis- 
engage all the adhesions possible, than to leave inflammatory masses 
untouched. Pay especial attention to the condition of the ovary on the 
supposed unaffected side. 

3. Eemove all blood and cleanse accessible soiled areas, but do not 
irrigate. 

4. Do not use tubular drains, but drain the various infected regions 
with long narrow strips of gauze, drawn out like rope the size of a lead- 
pencil, bunching them together, and sufficient in number at the lower 
end to form a large drain, which will keep the vaginal opening stretched 
wide, and produce pressure on the vaginal and cellular vessels behind the 
cervix. The many bunched-up, small, rope-like strips of gauze are much 
less painful to remove than the larger gauze drains ordinarily employed. 

5. Interfere with the patient as little as possible after the operation. 
If symptoms do not demand a change, allow the first drain or packing 
to remain in place for six or eight days; then remove it carefully and 
replace it by four or five small pieces, making a drain the size of a large 
forefinger, which should be allowed to remain in place for four or five 
days. Remove and replace once more, and in from fifteen to eighteen 
days remove the last drain and give vaginal douches. There will be a 
discharge for some time, but in three weeks fourteen out of fifteen of 
these patients will be practically cured. 

2. After the Fourth Month. 

General Considerations. When an ectopic gestation has advanced well 
into and beyond the fifth month, there are various considerations of 
importance bearing directly upon the safety of the mother which demand 



ECTOPIC GESTATION. 381 

recognition and call for the greatest exercise of judgment on the part of 
the surgeon. The development of the sac, the increase in the size of the 
bloodvessels, the development of the placenta, and the probable presence 
of adhesions, all combine to increase the danger of interference very 
materially. As the gestation advances the whole mass does not present 
itself as a small lump around or on either side of which a ligature can 
be drawn and easy resection performed, but as a complicated condition 
presenting the most complex variations. 

In cases at or near term the life of the child is a consideration of great 
importance. Although voluminous arguments have been advanced advo- 
cating interference while the child is living, no definite rule can be laid 
down on this subject, and the peculiarity of each individual case must 
be the guide to the course to pursue. It is justly held by most humane 
surgeons that the life of the child should be held subordinate to that of 
the mother, and that, if extra risks are to be encountered by the latter 
in order to save the infant, it must be clearly understood that the respon- 
sibility must not rest upon the physician managing the case. 

When an advanced case comes under observation for the first time, say 
at the sixth month of gestation, shall the surgeon wait until the eighth 
month, and operate with the intention of saving the life of mother and 
child, or shall he operate at once, or shall he wait, as advised by some 
authorities, until spurious labor has occurred, that there may be less risk 
in the operation? These questions are most perplexing, but many 
patients present certain peculiarities or conditions that may aid us in 
reaching a conclusion. 

A woman may be so reduced by repeated attacks of circumscribed 
peritonitis, recurrent moderate hemorrhages, and excessive pain that she 
can neither endure an operation nor continue in her present condition. 
In such a case, and there are such, the proper treatment is to resort to 
the old method; pick out some prominent foetal part, either abdominally 
or vaginally; insert a hypodermic needle deeply into the part, with aseptic 
precautions, and inject sufficient morphia, say half a grain, to kill the 
child, but not enough to harm the mother. If the child dies, placental 
souffle will disappear, the pain will subside, some considerable part of 
the liquor amnii will be absorbed, the dyspnoea will become less, and no 
more hemorrhages will occur, and in three or four weeks an operation can 
easily be performed. 

With a woman of strength and good health, with a child presenting 
favorably, and with a placenta that can apparently be easily avoided, the 
writer would advise endeavoring to save the child. At best, the dangers 
are always great, and, unless all symptoms are most favorable, the infant 
life should be ignored. 

Surgical interference in one way or another becomes necessary in 
almost all cases of advanced ectopic gestation, such interference being 
generally much safer than nature's efforts at relief. Patients with 
advanced ectopic gestation do not recover with ease without surgical aid, 
nor after careful analytical examination is the diagnosis usually obscure. 

As the foetal sac increases in dimensions the liability to sudden rup- 
ture, so characteristic in the earlier months, seldom occurs. The abdo- 
men is more completely filled and the adhesions more complete, causing 
more pressure and leaving less and less free space for large hemorrhages. 



382 PATHOLOGY OF PREGNANCY. 

Although the general diagnosis of ectopic gestation can usually be 
made with comparative ease, the difficulty of differentiating the variety 
becomes more difficult because of the occurrence of frequent small hem* 
orrhages and the presence of irregularly situated masses of exudate, the 
result of localized peritonitis. 

The object of all operations on ectopic gestation is the removal of the 

whole gestation sac, and this usually mean.- removal of the affected tube 
in early eases. In advanced cases this 18 often impossible, but as the 
foetus is the most offending part of the gestation it is always removed, 
and, as absorption of the placenta and sac is a slow and more or less 
dangerous process, they should also be removed when possible. 

Hemorrhage is the greatest danger in these operations, and, therefore, 
avoidance of the placental site when practicable is of the utmost impor- 
tance. This danger is almost entirely eliminated soon after the death of 
the child, and the most favorable time to operate is after that occurrence, 
but before definite signs of sepsis become manifest. Wait two or three 
weeks, if possible, until the placental souffle has ceased, but be ready to 
operate at the least indication of sepsis. 

Because of this liability to hemorrhage, all these operations must be 
performed quickly and the parts brought well into view; therefore, in 
aseptic cases, which are those that bleed, when the child is supposed to 
be living, abdominal section is almost always the operation of choice. 

When the child is dead and the placental souffle extinguished, it may 
occasionally be found advisable to operate per vaginam if the child is 
very superficially felt in the posterior cul-de-sac, and there appears to be 
no bar to extraction by that route because of the size of the foetus. The 
cases in which this method is advisable are, however, extremely rare, the 
difficulty of reaching and properly detaching the placenta being greater 
by the vaginal route. 

The vaginal incision will usually prove available only for the cases in 
which sepsis is well developed and the gestation sac is filled with putrid 
material and a decomposed foetus, and presents in the vagina in such a 
manner as to form a clear indication. 

The abdominal incision need not be median. The surgical sense of 
the operator must indicate the incision by which the foetus can best be 
reached and the placenta avoided. 

As removal of the foetus is a matter of necessity, its location becomes 
a guide to the character of the operation. It must be remembered, how- 
ever, that the exact site of the child and its relation to the peritoneum 
are frequently not determinable until after the incision is made, and 
sometimes not even then, but nevertheless a proper understanding of the 
peculiarities of the different varieties of cases materially assists intelligent 
treatment. 

(a) When the Fcetus is in the Unruptured Tube. If the ges- 
tation is of the infundibular variety there is great doubt whether it can 
ever develop so as to be included in the category of advanced unruptured 
tubal pregnancy. The very great majority, if not all, the cases are, 
therefore, ampullar or interstitial. In the latter variety the uterus has 
been dilated, its fundus cut through, and the child extracted. The proper 
and reasonable treatment, however, is simple abdominal section, made, 
if practicable, over the most prominent protuberance of the tumor, usually 



ECTOPIC GESTATION. 383 

near the median line and low down. The external layer of the sac, or 
rather the tube, is often found adherent to the anterior wall of the abdo- 
men, and the sac may frequently be freely opened without entering or 
even perceiving the free abdominal cavity. Every care should be taken 
to endeavor to avoid the placental site by careful and frequent ausculta- 
tion before the operation, and by carefully deviating the inner incision, 
if possible. 

The sac being opened, the child is at once extracted, and passed to an 
assistant, another assistant devoting his attention during this time to the 
compression of the broad ligament at each side of the sac. The upper 
border of this ligament on the affected side, if it can be isolated, may be 
ligated before the sac is opened. 

The important step is the management of the placenta. If the child 
was living when the operation was begun, and the placenta was not mate- 
rially injured during the operation, great surgical sagacity is needed to 
determine whether its extraction should be attempted. If it is con- 
veniently situated and the surgeon has faith in his ability to control the 
blood-supply, it may be rapidly shelled out and a firm packing of gauze 
relied on to control the hemorrhage. If deeply attached and the large 
lower vessels are inaccessible because of adhesions, the placenta may be 
left in place and a firm gauze tampon relied on to check the flow of blood. 
If the child has been dead for a few days the placenta may be removed 
at once with only slight risk. No attempt should, as a rule, be made to 
remove the sac in this variety of cases. If the sac or uterus or both 
has been extensively lacerated, and hemorrhage seems uncontrollable, it 
is better to remove the uterus and sac together. 

The edges of the incision in the sac should be sewed to the edges of 
the abdominal wound and the cavity packed with gauze, whether the 
placenta is removed or left in place. In the latter case, after a few days, 
the placenta can usually be removed with much less risk. If at any 
time, however, sepsis occurs, immediate removal of the placenta becomes 
imperative. 

(6) When the Fcetus is in the Abdominal Cavity. These are 
usually, if not always, cases in which the gestation was originally tubal, 
and in which primary or secondary rupture into the free cavity took 
place so gradually that no very general hemorrhage occurred, and the 
foetus simply lies in a sac formed of the chorion and amnion, which in 
time becomes attached indiscriminately to most of the adjoining struc- 
tures. Removal of the sac with the placenta in this variety is very 
difficult, tedious, and dangerous. After the abdomen is opened a place 
is found where the vessels are least numerous, the sac opened at this 
point and the child extracted. Unless the case is septic no attempt should 
be made to remove the placenta, which is usually deeply embedded in the 
pelvis at its original site. The sac is carefully packed with gauze, which 
is left protruding from the lower angle of the wound. The sac wound 
is attached, if possible, to the abdominal wound, and the abdominal 
wall closed down to the gauze at the lower angle. After a few days 
some of the stitches can be removed, and the placenta extracted, a new 
packing being carefully placed in the sac. If practicable, the ovarian 
artery should always be ligated on both sides of the mass. 

The abdomen should be bandaged rather snugly, excepting exactly 



384 PATHOLOGY OF PREGNANCY. 

opposite the drainage, lesl removal of pressure provoke hemorrhage. In 

BOme oases the placenta may have spread out rather thinly over a greal 
part of the anterior surface of the thin sac, and may be encountered 

above at almost all points. 

If the child is Miialland packed down in the pelvis, and appears 
within easy reach by the vagina, it may in rare instances he extracted 
with more ease through a vaginal incision. 

(<?) \Vm:\ the Fcetus is SUBPERITONEAL. The treatment differs 
but little from that of the varieties just described; but mention should 
be made here of two points : As the peritoneum is pushed upward and 
toward the unaffected side, the incision must be very low and often some- 
what oblique, so as to reach the sac without entering the general cavity. 
The mass cannot be removed, because it is undefined, the membranes and 
peritoneum having become blended and fused together so as usually to 
obliterate even the semblance of a sac. 

The operations just described are frequently extremely hazardous, and 
it is well to bear in mind that the primary object of interference is the 
removal of the foetus. At this juncture the exact conditions of the 
patient must carefully but quickly be determined. If the operation is 
then proceeded with, it may be necessary at a moment's notice to leave 
the removal of the sac unfinished and trust to firm packing with gauze 
to control the hemorrhage. Some operators have simply tied off the 
umbilical cord as near the placenta as practicable and have closed both 
sac and abdominal w r all without drainage, and with reasonable success, 
although the advent of sepsis renders early reopening and placental 
extraction necessary in the majority of cases. 

When in an advanced ectopic gestation the foetus is dead and symp- 
toms of sepsis make it manifest that suppuration has occurred, the sac 
should be opened, all its contents removed, and drainage established. 
Whether this should be done through an abdominal or a vaginal incision 
depends upon the peculiarities of the individual case. Ordinary surgical 
sense must enable the operator to determine the easier route, for with due 
precautions regarding the rules of asepsis the easier method is generally 
the safer. The proper combination of the two may be advisable; for 
example, with a great deal of pus presenting plainly in the direction of 
the vagina, and a large foetus, it may be better to make an incision below 
and evacuate the most of the liquid contents, or have a competent assist- 
ant do this, and immediately open above and extract the child. 

If pus has already found its way into the bladder, and the foetus is 
much macerated, and already partially in the viscus, the latter may be 
opened from the vagina and the child extracted piecemeal. If the same 
accident has occurred by way of the rectum, the anus may be dilated and 
delivery be effected, or rather assisted, from that direction. Or vaginal or 
abdominal incision may be made if these other methods seem impracti- 
cable or too dangerous. Common sense and surgical ability point out 
the direction attended with the least risk. 

When a patient formerly the victim of ectopic gestation comes under 
our observation only after the foetus has become mummified or has under- 
gone adipocere or calcareous formation, if the symptoms demand inter- 
ference, the operative indications already presented as applying to a 
recently dead foetus will suffice. 



ECTOPIC GESTATION. 385 

Repeated Ectopic Gestation. 

A number of instances are recorded in which one tube having been 
removed for ectopic gestation, impregnation has occurred at a later date 
in the remaining tube, as has been determined by operation or autopsy. 
Several cases have also been reported in which undoubted proof has been 
furnished of two or even three gestations in the same tube. Uterine 
pregnancy in the presence of a retained foetus, the result of a previous 
extra-uterine pregnancy, has been frequently noted. This may interfere 
mechanically with delivery, and its removal may become necessary. 

Twin Ectopic Gestation. It is claimed that twin pregnancies may occur 
outside of, the same as within, the uterus, but recorded cases of the kind 
are rare, and very few of these are so perfectly described that their validity 
is indubitable. 

Concurrent Ectopic and Uterine Gestation. Concurrent ectopic and 
uterine pregnancy may progress equally even to full term, or either foetus 
may prematurely perish. The treatment of such cases when pregnancy 
is advanced presents the most formidable complication known to the 
obstetric surgeon. When operation has been attempted, both children 
being alive and near term, there is no recorded instance in which the 
mother has survived. Although text-books do not prescribe the course 
to pursue, this experience furnishes an indication for treatment. 

Two courses may be followed : 1. As soon as the diagnosis has been 
established, the extra-uterine foetus may be sacrificed. It is rare that the 
advanced extra-uterine foetus cannot be safely reached with a fine explor- 
ing-needle. Sufficient morphia, say one-third to one-half a grain, may 
in this way be injected into the body of the child, thus destroying its 
life without injuring the mother. Ten days or two weeks later, or at the 
slightest indication of sepsis, uterine contractions may be gently and care- 
fully brought ou, and a reasonable chance thereby be given to both the 
uterine child and the mother. The extra-uterine foetus can be dealt with 
later, according to the indications. Even if interference becomes neces- 
sary very soon after delivery, this secondary operation would be much 
more likely to be successful because of the probable elimination of abdom- 
inal hemorrhage, which is the predominant danger in all such cases. 

2. Labor may be carefully induced and the ectopic gestation ignored 
and treated independently at a later period. A case was reported from 
Chrobak's Clinic in February, 1896, in which abdominal section was 
performed on a woman who had been delivered of her uterine child five 
days before, and a living child extracted from the abdomen. It was 
found necessary to remove the uterus with the gestation-sac. Mother 
and both children survived. 

The general advice may be given : Never operate on an advanced living 
ectopic gestation in the presence of an advanced living concurrent uterine 
pregnancy. 

Cornual Pregnancy. Arrest in the development or failure of coales- 
cence of the Mullerian ducts in foetal life may result in what is known 
as a bicornate uterus. When pregnancy occurs in one of the horns of 
such a uterus, the pregnancy may result in normal delivery, providing the 
horn is well developed. If, however, the horn is rudimentary and does 
not communicate freely and properly with the lower genital tract, we have 

25 



;**<; 



PATHOLOGY OF PREGNANCY. 



a condition bo closely resembling real ectopic gestation that it is usually 

described in the treatment of this subject. 

The Bymptoms, course, and treatment of this condition require no 
further consideration than the statement that it is to all intents and pup- 
poses an ectopic gestation, presenting the same signs and requiring sim- 
ilar treatment. 

Utero-abdominal or Traumatic Ectopic Gestation. A pregnant uterus 
mav rupture, the foetus may escape mid develop in the abdominal cavity, 
the placenta retaining sufficient attachment to nourish the child. Leo- 
pold has reported such a case operated upon at term. 

Fig. 251. 




Utero-abdominal or traumatic ectopic gestation. 

The following case came under the writer's observation in 1895 : The 
patient, in the desire to terminate an existing pregnancy, introduced a 
sharp instrument into the uterus when about seven weeks pregnant. 
After two and a half months of intermittent suffering attended with 
subacute septic symptoms, an operation w T as performed which revealed 
the condition represented in Fig. 251. The foetal sac still intact, about 
four or four and a half months advanced, was found in the free abdom- 
inal cavity, where it had been developing since the injury which caused 
its expulsion from the uterus. The placenta was still adherent to its 
original site, but had become attached to the uterine rent and to the 
adjoining external uterine surface. 



CHAPTER XVIII. 

DISEASES OF PBEGNANCY. 

The relation between the sexual organs and the general economy in 
woman is an intimate one. While the gravid woman is subject to the 
same general diseases as other women are, she is also liable to various 
morbid processes dependent upon the gravid condition. It is with the 
latter that we now have to deal. These will be considered in the fol- 
lowing order: disorders of digestion, of circulation, of respiration, albu- 
minuria, and disorders of the nervous system. 

Disorders of Digestion. 

Anorexia. By anorexia is understood a lack of desire for food. 
While occasionally there is no loss of appetite during pregnancy, the 
vast majority of gravid women suffer more or less, particularly in the 
early months, from this cause. When it is dependent solely upon the 
sympathetic relation between the developing uterus and the organs of 
digestion, little can be expected from treatment by drugs. A suitable 
dietary should be ordered. The more substantial articles of diet should 
be replaced with light and easily digestible liquid or semi-solid foods. 
Some simple laxative given often and in small quantities, as the fluid 
extract of cascara sagrada, ten to twenty minims three times daily, or a 
seidlitz powder in the morning, if necessary, to promote daily evacua- 
tions of the bowels, together with a bitter tonic, as gentian or cinchona, 
or one of the mineral acids before meals, may frequently be prescribed 
with benefit. The use of alcohol, in the form of light wine, taken with 
the meals, may sometimes be recommended. 

Pyrosis. Acid eructations, with a sensation of burning, extending from 
the throat to the epigastrium, which persists for some time after taking 
the smallest amount of food or even water, is commonly observed during 
pregnancy. At times the pain may be severe, extending through to the 
region of the scapulae, and attended with tenderness over the pit of the 
stomach. The affection is sympathetic, and the treatment for the most 
part symptomatic. Alkalies, such as the bicarbonate of sodium or calcined 
magnesia, given after meals, or some of the effervescing alkaline mineral 
waters with the meals, generally afford relief. Half-drachm doses of 
aromatic spirits of ammonia are frequently useful. The bowels should 
be regulated. 

Pica or Malacia. Pica or malacia occurs either alone or in conjunc- 
tion with the foregoing disorders. By these terms is understood a 
craving for unnatural articles of food. Pregnant women have been 
known to devour ravenously such things as plaster from the walls, char- 
coal, clay, chalk, and slate pencils. In some instances the woman mani- 
fests marked fondness for certain vegetables, acids, or ordinary foods and 

(387) 



388 rA Til o LOO Y OF PKEGNAXCY. 

drinks which were previously distasteful to her. All efforts at controlling 
the abnormal cravings of these patients arc usually futile; the most that 
can be done is bo prevent them from obtaining Bubstances thai are abso- 
lutely harmful. The affection is purely a psychosis. 

Vomiting. Of the disorders of the digestive tract common to preg- 
nancy this is the most important, not only because of the inconvenience 
and distress it causes the patient, but of the difficulty often encountered 
in it- successful treatment. It is customary to recognize two forms of 
this affection: simple vomiting and pernicious or uncontrollable vomiting. 

Simple Vomiting. The vast majority of pregnant women suffer 
at some period, most constantly during the second and third months, 
from nausea and vomiting; indeed, it is so intimately associated with 
the pregnant state as to be classed among the early presumptive signs 
of pregnancy. Sometimes the trouble reappears just before the com- 
pletion of pregnancy. In rare cases it begins shortly after conception, 
and continues through the entire nine months without interruption; in 
exceptional instances the cessation of vomiting is observed to be con- 
current with the appearance of diarrhoea. This would seem to imply 
that the reflex disturbance may act through different channels. The 
prognosis in simple vomiting is good, the natural outcome being recovery 
before the period of quickening. 

Causes. The number and diversity of theories which have been offered 
in explanation of the vomiting of pregnancy bear witness to our imper- 
fect knowledge of the subject. It is sufficient to say that the essential 
cause is reflex irritation from the growing uterus. 

Predisposing causes are excessive irritability of the nervous system, 
congenital or acquired, and anatomical lesions of the generative organs, 
such as misplacement of the uterus, endometritis, hyperplasia with indu- 
ration of the cervix, uterine injuries by blows or falls, pelvic adhesions, 
ovarian disease, or inflammation of the peritoneum. 

Symptoms. Toward the end of the first or at the beginning of the 
second month of gestation, the patient notices, for the first time, slight 
nausea upon rising in the morning; this may be followed, in a short 
time, by vomiting. In other cases the symptoms appear only after 
eating, perhaps after the lapse of one or two hours. Exceptionally the 
woman vomits only at night after having been in bed for some time. 
The ejected matter consists of thick glairy mucus, having a pronounced 
acid reaction, sometimes preceded or followed by one or two mouthfuls 
of clear watery fluid. Bile and partially digested food may also be 
vomited, if the act follows a meal. There is usually more or less retch- 
ing; this subsides after vomiting once, and the patient feels comparatively 
well. At times, the vomiting is preceded by an interval, more or less 
prolonged, of intense nausea, which exhausts the patient even more than 
vomiting. This latter condition is seen for the most part in neurotic 
patients. In some cases these attacks of vomiting occur from six to 
eight times during the twenty-four hours, just after or during a meal, 
following some sort of physical or mental exertion, or emotional disturb- 
ance, especially anger or fright. In the majority of cases the vomiting 
continues as above described, with, at times, slight exacerbations during 
the second and third and perhaps the fourth month, and then gradually 
diminishes in frequency; by the middle of gestation it usually ceases. 



DISEASES OF PREGNANCY. 389 

Fortunately, the pregnant woman bears this affection extremely well, 
and rarely suffers much impairment of nutrition. 

Pernicious or Uncontrollable Vomiting. It is customary to 
speak of the vomiting of pregnancy as uncontrollable when it is so 
severe and persistent as seriously to jeopardize the woman's life and 
when it will not yield to the usual remedial agents. Fortunately, these 
cases are rare. Dubois makes three stages of this affection : 

First Stage. The uncontrollable form of vomiting rarely begins 
abruptly, but, as a rule, develops gradually during the early months of 
gestation. There is nothing characteristic about the affection at first, 
except the fact of almost constant vomiting, which steadily increases in 
severity till the smallest amount of food or drink swallowed is instantly 
rejected. The matter vomited consists of thick glairy mucus, whatever 
food happens to be in the stomach, and bile. At times the ejected mucus 
may be streaked with blood, and the patient may suffer with more or 
less intense epigastric pain, attended with tenderness on pressure over the 
region of the stomach. There is present the greatest possible aversion 
to food of any description. Very soon the patient begins to present all 
the evidences of marked physical and mental depression, altered features, 
emaciation, more or less constant pain, and great weakness. During 
this stage the temperature remains normal, or nearly so; ptyalism and 
diarrhoea are not infrequent accompaniments, occurring either together or 
alternately. 

Second Stage. As the patient enters upon the second stage, a rise 
of temperature occurs toward evening. This is probably due to auto- 
intoxication arising from the absorption from the intestinal tract of the 
products of incomplete digestion. All the symptoms increase in severity; 
the fever becomes continuous, the temperature ranging between 101° and 
103° F., the pulse from 120 to 140. The extremities are usually cold 
and bathed in a clammy perspiration. The mouth and throat become dry, 
there is an intense thirst, and the tongue is covered with a heavy, dark 
brown crust. Soon sordes appear on the teeth, the breath is extremely 
fetid, and the diarrhoea, which is present, rapidly passes into incontinence 
of feces. The urine is scanty, of high specific gravity, offensive odor, 
and contains albumin and casts. The extreme emaciation and weakness 
of the patient, together with frequent attacks of syncope, constitute a 
condition calculated to excite the gravest apprehesion. 

Third Stage. It is a curious fact that as the patient enters upon the 
final stage there is usually a complete subsidence of the vomiting, while 
the temperature steadily rises, and the pulse becomes weaker and more 
irregular. Symptoms of cerebral disturbance now manifest themselves, 
intense lancinating pains in the head, hallucinations, delirium, and finally 
coma terminates the scene. In some cases the sensorium is not affected. 

The course of the affection, however, is extremely variable. There 
may be complete intermissions, the vomiting ceasing for days at a time, 
without obvious reason. But just as suddenly may all the distressing 
symptoms reappear, and with increased severity. The duration of the 
malady is sometimes two or three months. It is unusual for death to 
occur within a month from the onset of the symptoms. 

Diagnosis. The diagnostic examination should seek to determine the 
cause of the vomiting. A careful exploration of the pelvic contents 



390 PATHOLOGY OF PREGNANCY. 

Bhould always be made in the pernicious vomiting of pregnancy. Some- 
times the cause may be found in -nine anatomical Lesion of the pelvie 
organs which is capable of easy correction. Complicating causes, as, 
for example, nephritis, peritonitis, primary gastric disease, and other 
causes of vomiting independent of gestation, should be sought for. 

Prognosis. In uncontrollable vomiting of pregnancy the prognosis is 
always grave. The mortality ranges from 30 to 60 per cent. Joulin 
reports 12] cases with I!) deaths. Of 57 cases without treatment, 28 
proved fatal, while of 36 treated by inducing abortion, only 9 died. In 
the firsi Btage, under judicious management, the outcome is usually favor- 
able; in the second stage, more than one-half succumb; while in the 
third stage the prognosis is uniformly fatal. The reflex disturbance 
usually terminates after evacuation of the uterus, but not always. The 
vomiting may continue for a time even after the uterus is emptied, and 
may even go on to a fatal termination. 

Treatment. The treatment may be considered under three heads : 1. 
Dietetics. 2. General Therapy. 3. Surgical Measures. 

1. Dietetics. The diet must be light and easily digestible, and must 
be regulated according to the necessities of the individual case. In some 
instances a glass of iced milk taken in the morning, before rising, will 
be retained. If the patient objects to milk, koumyss served in the same 
manner, matzoon or other carbonated drinks may be acceptable. Pre- 
digestion is often of service. A glass of sherry, a cup of hot coffee, or 
even a cup of hot water given immediately on waking may serve a useful 
purpose. It must not be forgotten, however, that the stomach is capri- 
cious, and articles apparently difficult of digestion are often eagerly taken 
and retained by the pregnant woman. 

In refractory vomiting rectal alimentation is of the greatest value; 
when the stomach is unable to retain even the smallest quantity of liquid 
nourishment, it becomes the only means of keeping the patient alive. 
Milk, concentrated broths, beef peptonoids, and predigested eggs may 
be administered per rectum. Nutrient enemata are administered in 
concentrated form; the quantity may be from four to six ounces, every 
six hours. If too much is given, it will excite peristalsis and be expelled. 
Under skilful management the nutrition of the patient may be main- 
tained for many weeks by rectal feeding. S. H. F. Campbell cites a 
case in which the patient w r as sustained for fifty-two days by this means. 
It is well to wash out the bowel once daily during rectal alimentation. 

2. General Therapy. The medicinal treatment should concern 
itself first with functional disturbances of the digestive tract, which may 
be the chief exciting cause of the vomiting. Often there is constipation, 
with coated tongue, foul breath, and muddy complexion. In such cases 
a five-grain pill of mass, hydrarg., given every third night, and followed 
with a heaping teaspoonful of the phosphate of sodium in a glass of hot 
water in the morning, and perhaps accompanied with ten grains of 
bismuth subnitrate before meals, will be useful. Among the remedies 
most commonly employed for the control of the reflex disorder are : 
Cocaine, gr. ^, hourly till four or five doses are taken; oxalate of cerium, 
gr. x., three or four times daily; three-minim doses of the dilute hydro- 
cyanic acid given in carbonated water after meals; chloral or the bromide 
of sodium in doses of 60 to 120 grains daily by the rectum. The 



DISEASES OF PREGNANCY. 391 

chloral is best administered in milk. Minim doses of the wine of ipecac 
given every hour for several doses are occasionally useful. One or two 
drops of creosote or carbolic acid, well diluted, and given several times 
daily, are sometimes effective. Three- to five-grain doses of antipyrine 
have been recommended. Trional, fifteen grains, twice daily, has been 
used with success. Some of the gastro-intestinal sedatives and anti- 
septics, as bismuth subnitrate, bismuth subgallate, beta-naphtol, resor- 
cin, sulpho-carbolate of zinc, thymol, menthol, or the oil of gaultheria, 
may be tried. Small doses of the tincture of nux vomica, one or two 
minims every hour for several doses, are valuable in chronic gastric 
catarrh. In extreme cases, morphine, administered subcutaneously, will 
usually bring relief, at least for a time. The after effects of opiates, 
however, are usually bad. Spraying the fauces several times daily with 
a 2 J per cent, solution of cocaine hydrochlorate is frequently effective. 
Cold packs to the spine or ether spray applied several times daily, up 
and down the spine, will sometimes prove of benefit. Blisters or stimu- 
lating liniments applied over the fourth or fifth dorsal vertebra may 
be tried. The use of simple domestic remedies is frequently effective. 
At times obstinate vomiting, which has resisted numerous drugs, will 
entirely cease with the use of such apparently trivial measures as eating 
pop-corn, or the use of chewing-gum, after meals. 

Geoffroy thinks the vomiting is often due to hyperesthesia and spasm 
of the ilio-pelvic angle of the colon, causing secondary contraction of 
the pylorus and duodenum. Prolonged massage over the ilio-pelvic 
angle of the colon is at once a diagnostic and a curative measure. From 
one to three sittings usually suffice. 

3. Surgical Measures. Surgical measures are frequently indicated. 
Moreau and Graily Hewitt believe that uterine displacement is often 
accountable for the trouble, and that in such cases the treatment should 
be addressed to the malposition. The application of a solution of nitrate 
of silver, grs. xx. or lx. to the ounce, over the portio vaginalis and within 
the cervix, is sometimes useful. If this method is adopted care must 
be taken that the application does not reach too high in the canal, lest 
abortion follow. Cervical erosions should be touched once in two days 
with similar solutions. Copeman practised dilatation of the cervix with 
the finger. The dilatation may be more conveniently and more surely 
effected with a steel branched dilator. This method has been warmly 
praised by Munde, Wylie, Goodell, and others. The procedure, how- 
ever, should be withheld as one of the last resorts, since it is liable to 
induce abortion. Kehrer's method of cervical tamponing may be 
employed as" a substitute for that of Copeman or its modifications. A 
funnel of gauze is pushed into the cervix, which is then packed with 
narrow strips of gauze. The uterine cavity proper should not be 
invaded. The vomiting is, as a rule, speedily relieved, and the gauze 
may be removed at the end of twelve to twenty-four hours. Should the 
vomiting recur the tamponing is renewed for the same length of time. 
This method, like Copeman' s, should be reserved for cases in which 
artificial abortion is justifiable. When simple measures fail, the evacua- 
tion of the uterus must be considered. While the induction of abortion 
should be withheld so long as there is reasonable expectation of relief 
by other means, it must not be too long delayed. After prolonged inani- 



392 PATHOLOGY OF PREGNANCY. 

tioo the woman is liable to fall rapidly into a condition of dangerous 

exhaustion and t<> die abruptly. 

The besi method <>1* evacuating the uterus in the fir.-t two months of 
gestation, and even in the third, is the rapid one with curette and dressing 
forceps. The cervix is firs! dilated to three-quarters of an inch or one 
inch with a branched steel dilator. The ovum is then curetted away with 

a -harp curette, or the placental tissue may be removed with uterine 
dressing forceps and the uterine walls curetted. No packing is required; 
a dose or two of ergot may be administered to prevent hemorrhage. 
For irrigating the uterine cavity only a sterilized salt solution or plain 
boiled water should be used. By the foregoing method the uterus may 
be emptied in fifteen minutes. 

In a matter involving so great moral and legal responsibility the physi- 
cian should always seek the support of competent counsel. 

Ptyalism, a hypersecretion of saliva, is sometimes observed during 
pregnancy. It usually occurs during the first half of gestation, and 
continues for several weeks or months. The phenomenon is probably 
of nervous origin. Recent observations give reason to believe that the 
essential cause is a toxic body of sialagogue properties. In exceptional 
instances the flow of saliva is so profuse as to necessitate the wearing of 
a napkin to absorb the discharge, which is constantly dribbling from 
the corners of the patient's mouth. In extreme cases the quantity of 
secretion may reach two or three quarts daily. 

Treatment is unsatisfactory. Small doses of the tincture of bella- 
donna, a mild astringent gargle, or mouth wash, or small bits of ice held 
in the mouth, are sometimes useful. Extract of viburnum prunifolium, 
gr. iv. every four hours, or a twelfth of a grain of pilocarpine two or 
three times daily, may be tried. Galvanization of the salivary glands, 
two or three milliamperes, for five or ten minutes once or twice daily, 
has been strongly recommended. 

Dental Caries. Severe neuralgia of the dental nerves and marked 
tendency to caries of the teeth are of common occurrence in pregnant 
women. That the teeth are more liable to decay than in the non- 
gravid is probably due to the acidity of the buccal secretions arising 
from gastro-intestinal disorders, and also to the altered state of the 
patient's blood. Special care of the teeth should be observed during 
pregnancy, and the patient should be advised to consult her dentist at 
frequent intervals. A dilute solution of listerine, 1 in 6, or other similar 
antiseptic mouth-wash is especially useful as a preservative. 

Diarrhoea. Diarrhoea is a not infrequent complication of pregnancy. 
The attack is most apt to occur at the menstrual dates. While usually 
mild and amenable to treatment, it is sometimes intractable, and in 
exceptional cases may lead to abortion. The treatment is the same as 
in other forms of diarrhoea. 

Constipation. Constipation is a still more frequent attendant on the 
pregnant state. The pressure of the enlarged uterus upon the upper 
portion of the rectum interfering mechanically with the passage of the 
feces, the paretic condition of the bowel following such pressure, and, 
finally, the diminished secretion of bile are possible causative factors in 
this disorder. Habitual constipation may lead to anorexia and other 
digestive disorders; the increased determination of blood to the pelvic 



DISEASES OF PREGNANCY. 393 

organs, and consequent venous stasis, may result in hemorrhoids or pro- 
lapse of the rectum. The latter conditions are aggravated by straining 
at stool. In neglected cases scybala may collect in sufficient quantity to 
cause abortion through irritation of the uterus. The patient suffers from 
autointoxication, the result of retention in the intestinal canal of excre- 
mentitious products. The treatment is the same as for habitual consti- 
pation occurring independently of pregnancy. A proper regulation of 
the diet is important. The morning meal should consist of fruits, coarse 
cereals, and those articles of food which have a laxative effect. Exercise 
in the open air and the observance of a regular hour for evacuating the 
bowels are essential. With some patients a cup of hot oatmeal gruel at 
bedtime proves effective, while with others a glass of beer taken at the 
same time is useful. 

If it be necessary to resort to medication, simple laxatives or some of 
the aperient mineral waters, rather than the more active purgatives, 
should be chosen. Fluid extract of cascara sagrada three times daily, 
compound licorice powder given in drachm doses at night, and the same 
amount of confection of sulphur once or twice daily, are suitable. 
Drachm doses of the phosphate of sodium in a cup of hot water may 
be employed, or the same quantity of Carlsbad salts each morning before 
breakfast. All these may be alternated with Vichy, Hunyadi, or any of 
the numerous aperient mineral waters, according to the taste of the 
patient. 

Disorders of Circulation. 

Palpitation, so common at some period of gestation, may, like the cough 
and dyspnoea, be caused by sympathetic disturbance, or be due to the 
mechanical interference of the enlarged uterus with the action of the 
heart. It is much more noticeable in thin, nervous women, or in those 
who are anaemic or chlorotic before pregnancy. Palpitation is a common 
symptom in hydramnios. It seldom calls for active treatment; rest is 
all that is usually required. The patient should be instructed to assume 
the reclining position when the palpitation is at all distressing. 

Fainting. Attacks of syncope are occasionally observed in thin, ner- 
vous women, sometimes in apparently robust patients. The attack lasts 
for a few moments, and may be followed by hysterical manifestations. 
The affection is of nervous rather than circulatory origin. The treat- 
ment consists in the administration of some of the diffusible stimulants, 
such as alcohol, aromatic spirits of ammonia, or camphor. Strychnine 
is generally useful. 

Varices and Hemorrhoids. The occurrence of varices of the lower 
limbs, genitals, or the anal region in the later months of gestation is not 
uncommon. They are most frequently observed in multipara?. They 
are of little pathological significance if not extensive. Venous obstruc- 
tion and lesions of the vascular walls are probably the determining causes 
of varices. Habitual constipation and most frequently the pressure of 
the gravid uterus are complicating factors in the causation of hemor- 
rhoids. The saphena is most frequently affected, next the veins on the 
inner surfaces of the thighs and legs, less often those of the vulva. 

The treatment is the same as in varices when occurring under other 
conditions, viz., rest, pressure, and support, when the veins appear on 



;;!U PATHOLOGY OF PREGNANCY. 

the thighs <>r legs, and the usual palliative measures for the relief of the 
hemorrhoids. For the latter regulation of the bowels is most essential. 
Rupture of enlarged veins should be guarded against lest the woman's 
life be Imperilled by hemorrhage. Surgical methods should, as a rule, 
be postponed till gestation is completed. 

Anaemia. The changes which the blood undergoes during pregnancy 
have already been discussed. In the early months of gestation increase 
in the watery constituents of the blood, with a corresponding temporary 
diminution in the red corpuscles, and a moderate increase in the white 
corpuscles, is physiological up to a certain point. By mid-pregnancy the 
blood is richer than before. Later there is an excess of fibrin over the 
non-pregnant state. Anaemia in pregnancy is always to be regarded as 
a pathological condition which demands active treatment. As Grusserow 
has pointed out, it may be severe enough to result fatally. In grave 
cases appetite fails, neuralgias develop, exertion becomes difficult or 
impossible, and purpura, chorea, and even insanity may result. The 
treatment in these cases aims at improving the general nutrition of the 
patient by an easily assimilated diet, animal food, eggs, plenty of out- 
door exercise, attention to the bowels, and the use of iron in some form. 
Mercuric chloride in doses of T ^ grain, is sometimes a valuable haema- 
tinic. Preparations of beef-marrow are frequently of service. In grave 
anaemias rest in bed must be rigidly enjoined. When stomach feeding 
is impossible, resort must be had to rectal alimentation. A combina- 
tion of arsenic and iron, as in arsenate of iron, is especially useful in 
the anaemia of pregnancy. Gusserow advises the induction of premature 
labor in extreme anaemia. 

Disorders of Respiration. 

The two most common affections of the respiratory system are cough 
and dyspnoea. The cough, like nausea and vomiting, is usually purely 
reflex in origin. Rarely it may become so severe and continue so long 
as to cause abortion. As in the majority of cases the disorder is of 
nervous origin, antispasmodics or sedatives will generally accomplish more 
than expectorants. A pill of valerianate of iron, quinine, and zinc, taken 
after meals, small doses of the tincture of belladonna, or the extract of 
cannabis indica, taken three or four times daily, or small doses of 
codeine, or bromide of potassium combined with some simple expectorant 
mixture will usually overcome the difficulty. 

Dyspnoea. The dyspnoea, like the cough occurring during pregnancy, 
may originate either reflexly, or, more commonly, during the later 
months of pregnancy from the mechanical pressure of the enlarged 
uterus upon the diaphragm. If the amount of liquor amnii is exces- 
sive, the lungs may be so crowded upward in the thorax that the patient's 
respiration is seriously interfered with. It is usually sufficient to instruct 
the patient to wear loose clothing, avoid excitement and much exertion, 
and to sleep with the head and shoulders elevated. 

Albuminuria. 

Albuminuria in the pregnant woman may be merely the continuation 
of an albuminuria which had existed before the pregnancy. Most fre- 



DISEASES OF PREGNANCY. 395 

quently it is the result of toxic conditions developed during gestation. 
In the large proportion of cases it occurs in women presenting no evi- 
dence of pre-existing renal disease. Occasionally it is met with in 
several successive pregnancies of the same patient, wholly disappearing 
in the intervals. In such instances there is reason to suspect the 
presence of a chronic lesion of the kidneys as a predisposing factor. In 
.all cases, it must be assumed, the presence of albumin in the urine has in 
greater or less degree a pathological significance. A strictly physiological 
albuminuria probably does not exist. 

Frequency. Renal albuminuria resulting from pregnancy is found 
in about 5 per cent, of pregnant women. The estimate, it must be 
remembered, does not include cases in which albumin is present in the 
urine from pyuria, from admixture of blood or of leucorrhceal discharges, 
or from a previously existing nephritis, or from the effects of labor. 
Albuminuria of pregnancy is encountered most frequently in hydremia, 
in excessive distention of the uterus, as in hydramnios, and in multiple 
foetation. The coexistence of abdominal tumors increases the tendency 
to albuminuria by increasing the intra-abdominal tension. It is more 
common in first than in subsequent pregnancies, owing probably to greater 
intra-abdominal pressure in the former. In by far the larger proportion 
of cases it appears only in the latter half of pregnancy. 

Etiology. Primiparity, and especially aged primiparity, is recognized 
as an etiological factor of the albuminuria of pregnancy. Its influence 
is explained by the greater tonicity of the abdominal muscles and the 
consequently greater intra-abdominal pressure which obtains in first 
pregnancies. 

Overdistention of the uterus, as in twins or hydramnios, is a causative 
factor. Albuminuria occurs more frequently in these conditions than in 
single gestation without excess of liquor amnii. 

Climatic conditions are doubtless sometimes responsible for the attack. 
Exposure to cold or dampness is a competent cause. Possibly spasm 
of the renal vessels, induced by reflex irritation from the gravid uterus, 
may in certain cases be responsible for the presence of albumin in the 
urine. Hydremia with high arterial tension favors the occurrence of 
albuminuria. The principal cause is the retention in the blood of certain 
toxic materials, the combined product of maternal and foetal metabolism. 

Diagnosis. The presence of albuminuria during pregnancy cannot 
escape detection under a proper system of observation. Systematic 
urinary examinations should be made occasionally, even in the earlier 
months of gestation; in the last two months, at least once weekly. 

Heat and nitric acid, the cold nitric-acid test, or Esbach's test (picric 
acid 10, citric acid 20, water 1000 parts) may be used. It is necessary 
to exclude such possible sources of error as the presence of blood or pus 
in the urine and of leucorrhceal discharges. 

Contamination by vaginal discharges may be prevented by the use of 
a vaginal douche immediately before voiding urine for examination. 

In cystitis the urine may contain traces of albumin. Cystitis is 
excluded by the history and by the gross and the microscopic appearances 
of the urine. 

Especially important is it to know the daily quantity of urine and 
the specific gravity, as evidence of the functional competence of the kid- 



396 PATHOLOGY OP PREGNANCY, 

neys. A quantitative determination of urea affords the most reliable 
evidence of their excretory activity. 

Microscopic examinations for the possible presence of casts are essen- 
tial. 

Prognosis. The prognosis depends upon the degree and persistence 
of albuminuria, upon the stage of gestation, and upon the degree of tox- 
aemia which accompanies it. Slight albuminuria, especially in the later 
weeks of pregnancy, is usually of little pathological significance. The 
presence of a Large percentage of albumin in the urine, especially if per- 
sistent and particularly in the early months, is of grave import. The 
danger of septic infection and of thrombotic affections is increased by 
albuminuria. The outlook for the child is bad in proportion to the 
degree of uraemia and the immaturity of the foetus. Albuminuria is a 
frequent cause of placental apoplexies and foetal death and premature 
delivery. 

Treatment. The gravity of the condition and the character of the 
treatment will be determined in great measure by the degree of toxaemia. 
So long as the quantity of urine is ample and the excretory activity of 
the kidneys is normal, as indicated by the total amount of solids, and 
especially of urea, eliminated daily, there is little need of treatment. 
When uraemia as well as albuminuria is present, as indicated by the con- 
dition of the nervous system, and especially by quantitative determi- 
nations of urea and of the total urinary solids, active measures are 
demanded. 

The treatment consists essentially in limiting the production of the 
disease poisons and in promoting their elimination. The first object is 
favored by the use of a milk diet. In marked albuminuria the diet 
should be entirely milk for one or two weeks or longer. When milk is 
not well borne, or a more liberal diet is required, soft-cooked eggs or 
gruel may be added. To favor the elimination of the poisons all the 
emunctories should be stimulated. The bowels should be opened once or 
twice daily with saline cathartics. The skin should be kept active by 
warm bathing daily and by warm flannels next the skin. The chief 
reliance for elimination is the action of the kidneys. The most effective 
diuretic is pure water. Water should be drunk freely. The temperature 
of the water ought not to be below 40° or 50°. Hot water is sometimes 
better borne than cold. The milder alkaline waters are especially suit- 
able. Should the quantity of urine still be insufficient, notwithstanding 
the free use of water, digitalis or some other cardiac stimulant is indi- 
cated. Tonics and restorative measures are usually required. Grave 
albuminuria in the last two months of pregnancy, which does not yield 
to dietetic and medicinal measures, calls for the evacuation of the uterus. 
The line of treatment to be adopted will depend in great measure on the 
degree of albuminuria and the stage of gestation at which it occurs. 
This subject will be more fully considered in connection with eclampsia. 

Disorders of the Nervous System. 

Neuralgia is a not infrequent affection of pregnant women. It is 
especially common in the dental nerves and in those of the pelvis which 
are exposed to pressure by the growing uterus. Pelvic pains are espe- 



DISEASES OF PREGNANCY. 397 

cially common in the subjects of old pelvic inflammation. The uterus 
and the breasts are frequently the seat of neuralgic affections. Abdom- 
inal pains, usually of neuralgic character, are often complained of in the 
later months of gestation. 

In the treatment tonics and restoratives are the measures usually indi- 
cated. Iron, arsenic, and quinine are especially valuable. Hygienic 
precautions in the matter of diet, sleep, and the regulation of the emunc- 
tories are always important. 

The endermic use of morphine in the form of oleate, when required, 
is free from the more important objections which obtain against the use 
of opiates internally. Severe pain is promptly relieved by the coal-tar 
analgesics. Three or four grains of acetanilid may be given and repeated 
hourly till three doses are taken, unless the pain is sooner relieved. It 
should be combined with caffeine, digitalis, or an alcoholic stimulant, to 
guard against the cardiac depression usually induced by the drug when 
given alone. Local sources of irritation should be sought for, and re- 
moved if possible. 

Mental Affections. Very commonly a more or less complete change is 
observed in the disposition and mental character of the woman during 
gestation. With neurotic women the condition of the nervous system 
frequently is, at the best, one of unstable equilibrium. This is especially 
true with gravidse who present a family history of insanity. 

Various hysterical manifestations are frequently observed, and most 
neurotics are troubled with insomnia. The general subject of puerperal 
insanity is discussed elsewhere. Attention should be paid to mental 
hygiene. Cheerful surroundings and reassuring influences are important 
therapeutic agents. Open-air exercise and recreation are indispensable. 
For the treatment of insomnia, a warm bath on retiring, a glass of milk, 
or a cup of hot broth taken at the same hour will sometimes prove effica- 
cious. Should it become necessary to resort to drugs, sulphonal or 
trional in twenty-grain doses, hyoscyamus, or perhaps codeine, can be 
administered, care being taken that the patient does not become dependent 
upon these hypnotic agents. 



PAKT VI. 

PATHOLOGY OF LABOR, 



CHAPTER XIX. 

ANOMALIES OF THE MECHANISM. 

Dystocia is the term applied to labor which, without artificial assist- 
ance, would be difficult or impossible, or would be attended with danger 
to mother or child. It is the opposite of Eutocia, which denotes normal 
labor terminating safely and easily without artificial aid. 

Every case of labor is a mechanical problem in which the three main 
factors are (1) the expelling force, (2) the foetus which is to be expelled, 
and (3) the resistance of the parturient canal, which must be overcome 
before delivery can be effected. If the expelling force is sufficient, and 
there is no disproportion between the foetus and the maternal passages, 
labor proceeds normally. As the foetus descends through the parturient 
canal more or less adaptation takes place; the presenting part moulds 
somewhat to the shape of the canal, while the maternal soft parts stretch 
and open out to make way for it, till finally it is expelled spontaneously, 
without serious damage to itself or to the mother. So long, then, as 
these three main factors are properly correlated, all goes well; but if 
their harmonious action be impaired, the normal mechanism of labor may 
be disturbed, and dystocia may be the result. The cause of the abnor- 
mal mechanism may be in any one of these three factors : the expelling 
force may be insufficient or excessive; the foetus itself maybe unusually 
large or small; the resistance of the maternal passages may be too great 
or too little. It is obvious, therefore, that in the management of a case 
of dystocia the recognition of the disturbing cause forms the basis of 
rational treatment, and should always therefore precede artificial assist- 
ance. 

Dystocia may be most conveniently described according to its causation 
in three sections, as follows : 

1. Anomalies of the expellent forces : 
(a) Excess — precipitate labor. 

(6) Deficiency — delayed labor — inertia uteri. 

(c) Spasm and irregularity— rigid os and cervix — tetanus uteri. 

2. Anomalies of the passages : 

A. Hard parts — pelvic deformities. 

Influence on pregnancy and labor; frequency. 

(399) 



400 PATHOLOGY OF LABOR. 

Diagnosis — From previous history and physical appearance. 
Prom mechauism of labor. 
Prom head moulding. 

From physical exam i nation — pelvimetry. 
(a) External measurements. 
(I)) Internal measurements. 
( JlassificatioD : 

1 'elves — Normally proportioned, hut abnormal in size. 
With anomalies of size, shape, inclination. 
With minor developmental peculiarities. 
Antero-posteriorly contracted. 
Obliquely contracted. 
Transversely contracted. 
Compressed. 
Spondylolisthetic. 

Distorted by injury, tumors, anchylosis of joints. 
With deformities due to spinal curvature. 
Individual forms particularly studied; relation to pregnancy and 
labor. 
B. Soft parts : 

Uterus — Developmental anomalies. 
Atresia of cervix. 
Rigidity of cervix. 
Impaction of cervix. 
Malposition. 
Sacculation. 
New growths. 

Stenosis and rigidity of vulva and vagina. 
Hematoma vulva?. 
(Edema vulva?. 
Labial abscess and cysts. 
Conditions of intestines. 
Conditions of bladder. 
Tumors and swellings of various tissues. 
3. Anomalies of the foetus : 
Malposition of the head. 
Occipito-posterior cases. 
Mai presentations : 

Face, brow, pelvic, transverse. 
Prolapse of the limbs. 
Anomalies of foetal development : 
Shortness of cord. 
Unduly ossified skull. 
Large size of foetus. 
Death of foetus. 

Enlargement of head or body by disease. 
Plural births. 
Monstrosities. 



ANOMALIES OF THE MECHANISM. 401 



1. ANOMALIES OF THE EXPELLENT FORCES. 

(a) Excess — Precipitate Labor. 

When uterine action is excessive the resistance of the maternal passages 
may be overcome violently or rapidly, and then labor is said to be pre- 
cipitate. The posture of the patient has an important influence upon the 
course and termination of such cases. In the dorsal or lateral position 
the pains are rarely strong enough to end labor so rapidly as to cause 
serious damage; but if the patient happens to be standing, walking, 
sitting, or squatting, a single violent pain may suffice to force the child 
completely through the passages. It may fall to the floor and be injured; 
the cord may be torn asunder and the placenta may be dragged from its 
attachments, or, remaining adherent, may pull the uterus along with it, 
causing inversion. If the patient happens to be sitting in a privy or 
water-closet, the child may fall into the cesspit or into the pan of the 
closet, and may perish before assistance can be procured. Not infre- 
quently the mother faints from shock or loss of blood, or she may become 
so bewildered and frightened that she does not realize what has happened 
until it is too late to save her child. Such cases sometimes give rise to 
important medico-legal questions, especially when the child is illegiti- 
mate and a charge of infanticide is laid. While undoubtedly it must be 
admitted that such cases of sudden delivery do occasionally happen, it is, 
nevertheless, very exceptional for labor to be so rapid that the patient 
has no warning of what is about to take place and has no time to seek 
assistance. As a rule, the first stage of labor is more or less normal in 
such cases, and it is only in the second stage that precipitancy occurs. 
If the membranes are tough and the amniotic sac descends very low 
before rupturing, then the sudden gush of water may sweep the pre- 
senting part violently down upon the perineum, and delivery may be 
completed at a single pain. It does not always happen that precipitate 
labor follows excessive uterine action. If the maternal soft parts do not 
yield to the expellent forces, but are rather provoked thereby to greater 
resistance, labor may be delayed, and the uterus may become exhausted 
by fruitless efforts, or may even rupture. Under such circumstances the 
child will probably perish, the placenta being compressed and the foetal 
circulation deranged by the prolonged uterine contraction. 

Causes. The chief predisposing causes are (1) an undue excitabilty of 
the sensory nerves of the uterine muscle, which frequently exists in ner- 
vous excitable women, 1 and (2) previous inflammatory conditions of the 
uterus, such as an old endometritis. Debilitating conditions which relax 
the tone of the pelvic floor favor precipitate labor by diminishing the 
resistance which is to be overcome. Dysmenorrhoea, oblique presenta- 
tions, pneumonia, and zymotic diseases (especially variola and scarlatina), 

1 Dr. Routh recently reported to the London Obstetrical Society a case of labor in a woman suffer- 
ing from complete paraplegia (traumatic) below the level of the sixth dorsal vertebra. The only 
sensation which the patient felt during a pain was a tight feeling at the epigastrium, causing her to 
hold her breath. Dr. Routh concludes that the act of parturition is partly automatic and partly 
reflex, and thinks that direct communication by means of the sympathetic between the uterus and 
the lumbar enlargement is essential to the regular and co-ordinate contraction and retraction of the 
uterus during labor. If this view be correct.it is obvious how powerfully uterine action maybe 
influenced by causes acting through the sympathetic, and how frequently the true cause of abnormal 
uterine action may be found in derangements of the nervous system. 

26 



402 PATHOLOGY OF LABOR. 

may also be mentioned as predisposing causes. Pear, anxiety, and pow- 
erful emotions are Baid to increase the force of uterine contractions, but 
it is probable that their action is not constant, and that undue exertion 
on the part of the patient, such as walking, is usually the exciting cause. 

Sequelae. The most important immediate consequences of precipitate 
labor are lacerations of the vagina, vulva, and perineum, partial or com- 
plete separation of the placenta, hemorrhage, inversion of the uterus, 
and delayed expulsion of the placenta. V iolent contraction of the Uterine 
muscle is apt to be followed by relaxation and atony, and hemorrhage 
may result. In the puerperium also many troubles may arise, such as 
oedema, retention of urine, hemorrhage, and septicaemia. Violent strain- 
ing efforts in rare eases have produced emphysema of the throat, neck, 
and chest from slight lesions of the trachea or bronchi; but this usually 
disappears in a few days without treatment. 

The foetal mortality is greater than in normal labor. The child's head 
may be injured by being driven forcibly against the promontory of the 
sacrum, and the cranial bones may be furrowed or even fractured. The 
child may be asphyxiated by undue compression of the foetal head or of 
the cord or placental site. It may be injured by falling violently upon 
the floor, or it may perish by dropping into a cesspit or water-closet. 

Treatment. If a previous labor has been precipitate, or if the uterine 
action is manifestly excessive or violent, the patient should not be allowed 
to stand or walk about, or to sit upon the closet, especially during the 
second stage of labor, but should be kept in bed and made to lie on her 
side. To moderate the violence of the pains, a dose of chloral (grs. xx 
to xxx) may be given, or a hypodermic injection of morphia (gr.^, or a 
few whiffs of chloroform may be administered at the beginning of each 
pain. The patient should be made to pant during her pains, and should 
not be allowed to hold her breath or bear down. Some authorities advise 
rupturing the membranes before the os is fully dilated. During delivery 
care should be taken to protect the perineum, the head being held back 
and prevented from descending too rapidly. Chloroform is invaluable 
at this stage. Great care should be taken in the management of the 
third stage of labor; plenty of time should be given for the placenta to 
separate, and the uterus should be kept under control for some time after 
the placenta has been expelled in order to guard against subsequent relax- 
ation. If the uterus does not contract well, or if it shows a tendency to 
relax, a copious hot intra-uterine douche should be given, followed by a 
hypodermic injection of ergot. The physician should not leave his 
patient until he is satisfied that the uterus is well contracted and that 
there is no further danger of hemorrhage. 

(b) Deficiency — Delayed Labor— Inertia Uteri. 

AVhen the uterine action is insufficient to overcome the resistance of 
the maternal passages, labor is delayed, and the pains are said to be weak. 
The weakness of labor pains is relative. Pains which would be strong 
enough for the first stage may be inadequate for the second stage. Pains 
which would be normal and efficient if the resistance were slight, may 
be inadequate, and, therefore, abnormal when the resistance is great. 
The true test of the weakness and inefficiency of labor pains on the one 



ANOMALIES OF THE MECHANISM. 403 

hand, or of their strength and efficiency on the other, is the advance of 
labor; whenever they are too short or too feeble to secure the normal 
progress of labor, they are weak. Mere sluggishness of uterine action, 
however, is not to be confounded with weakness. Sluggish pains recur 
at abnormally long intervals, yet they may be strong and efficient never- 
theless. 

Causes. The cause of deficient uterine action may be either in the 
uterus itself or in some other organ. There may be some congenital 
malformation, as the uterus bicornis, or the uterine muscle may have 
been weakened by previous inflammation, by menorrhagia, by repeated 
abortions, or by too frequent childbearing. Its fibres may be so stretched 
that they cannot contract efficiently, as in multiple gestation or hydram- 
nios. There may be malpresentation, or too early rupture of the mem- 
branes, or the attachment of the placenta may be faulty, as in placenta 
previa. New growths in the uterine wall, as inyomata; displacements 
of the uterus, as prolapsus, or deviations in its axis may all cause inertia. 
Uterine weakness in the third stage frequently occurs in precipitate labor; 
and, on the other hand, it is very likely to follow a prolonged and painful 
first and second stage. 

Very often the cause of weak uterine action must be sought elsewhere. 
A distended bladder or rectum, a dilated stomach or intestine, may so 
alter the position and axis of the uterus as to make its contractions pain- 
ful and inefficient. Sometimes the patient does not use her abdominal 
muscles properly and the uterus is unable to overcome the resistance of 
the parturient canal unaided. The physical strength of a patient is not 
always a correct index of the expulsive power of her uterus or of the 
ease of her labor; much depends upon her fortitude and pluck and the 
intelligent use of her voluntary muscles. Weak, delicate women (e. g. f 
consumptives) frequently have strong pains and easy labors, \v r hile robust, 
powerful women are often disappointing by reason of their weak pains 
and tedious labors. 

Long residence in tropical climates tends to cause uterine inertia. 
European women in India suffer from menorrhagia, uterine inertia, and 
post-partum hemorrhage. A luxurious and enervating life predisposes 
to inertia. Age has also a certain influence; in young primipara3 the 
pains are apt to be imperfect and irregular. Mental conditions, such as 
grief, excitement, and depression, often weaken the force of the uterine 
contractions. 

Symptoms. The symptoms depend upon the stage of labor. If the 
membranes are unruptured and weakness manifests itself during the first 
stage, the pains are short, the cervix dilates very slowly, the bag of mem- 
branes does not feel tense or press down into the cervix during a contrac- 
tion, the presenting part descends but slightly with each pain, and may 
easily be pushed back with the examining finger. If the membranes rup- 
ture early the presenting part advances slowly or not at all. The chief 
indication, therefore, of deficient uterine action in the first stage is delay 
or arrest of labor from imperfect dilatation of the cervix. Constitutional 
symptoms (elevation of temperature, pulse, and respiration) do not 
usually appear unless the delay is very prolonged. In the second stage 
the symptoms are chiefly those of pressure. If the presenting part is 
arrested but not impacted, the pressure symptoms may not be pronounced; 



In i PATHOLOQ V OF LABOR. 

but if impaction occurs, the vagina soon becomes hot, dry, swollen, and 
tender, the external genitals swell, and there may be cramps in the Legs 

and cutting pain- in the hack, loins, and abdomen. After a time con- 
stitutional symptoms develop, the pulse, temperature, and respirations 
rise, the tongue becomes furred and dry, nausea and vomiting may occur, 
the countenance becomes anxious, the face swollen, the patienl restless, 

and if she i- not promptly relieved, low muttering delirium supervenes 
and death ensues with symptoms of profound exhaustion. ThefoetllS, too, 

shows signs of distress; its movements become violent, the foetal heart- 
beat Increases and then rapidly decreases in frequency, and finally death 

oeeui- from asphyxia. 

Sometimes the uterine weakness is not general, but is confined to the 
fundus, the placental site, or a portion of the anterior or posterior wall. 
If the weakness is in the fundus, labor is usually slow; if in the anterior 
or posterior wall, the weakened portion bulges, and rupture may take 
place; if near the placental site, there may be deficient contraction and 
retraction during the third stage, and the placenta may be retained, or 
hemorrhage may occur. 

The effects of deficient uterine action upon the third stage of labor are 
important. The uterus may have acted well during the first and second 
stages, but may have become so exhausted that it cannot contract and 
retract satisfactorily during the third stage. Occasionally the weakness 
in the third stage is only the continuation of weakness in the first and 
second stages. Good uterine contraction is essential to the proper sepa- 
ration and expulsion of the placenta; hence when the pains are infrequent 
and weak, the placenta is apt to remain partially or wholly adherent, and 
in the former case hemorrhage occurs. After separation has taken place 
a weak uterus may be unable to expel the placenta and membranes from 
its cavity, and even after they have come away it may tend to relax and 
permit free hemorrhage or the formation of a large clot. 

Diagnosis. The diagnosis is made by making a vaginal examination 
during a pain and by palpating the abdomen externally. In the first 
stage of labor, if the bag of membranes does not become tense, and the 
presenting part does not descend during a pain, if the cervix does not 
dilate and labor does not advance, the uterine action is inefficient. If 
in the second stage the presenting part becomes arrested or impacted, if 
the maternal passages become dry, swollen, and tender, and especially if 
constitutional symptoms supervene, it is safe to conclude that the expel- 
lent forces are unable to overcome the resistance of the parturient canal. 
By palpating the abdomen it may be ascertained how frequent and strong 
the pains are, and whether there is any deviation in the axis of the 
uterus, or whether a distended bladder is interfering with uterine action. 
In doubtful cases the condition of the thoracic and abdominal viscera 
should be ascertained. 

Prognosis. The prognosis depends upon the stage of labor, the degree 
of weakness and its cause. In the first stage, if the membranes are 
unruptured there is usually very little danger for either mother or child; 
but if the membranes have been long ruptured the life of the foetus may 
be imperilled. In the second stage there may be danger for mother and 
child if labor is too much prolonged. According to some authorities, 
delivery cannot be delayed safely beyond seven or eight hours after rup- 



ANOMALIES OF THE MECHANISM. 405 

ture of the membranes. No such hard-and-fast ride can be laid down, 
since in some cases a long delay may be harmless, while in others a com- 
paratively short delay may entail serious consequences. The condition 
of the mother and child should be carefully watched in all cases of 
delayed labor. A slowing foetal heart foreshadows danger to the child, 
while local oedema and a rising pulse and temperature are maternal 
danger-signals which should not be disregarded. As a general rule, the 
longer the delay the worse is the prognosis for both mother and child. 
It is usually better in multipara than in primiparse, and better in partial 
than in total uterine weakness. Atony of the placental site and general 
atony of the uterus in the third stage are serious conditions, for they 
may lead to violent .or uncontrollable hemorrhage. 

Treatment. The treatment varies according to the stage of labor, the 
cause of inertia and its extent. The room should be kept cool, since 
heat favors uterine weakness. Visitors should be excluded and the 
patient kept free from excitement. If the cause of inertia can be ascer- 
tained, it should be removed if possible; a distended bladder or rectum 
should be emptied, a deflected uterine axis straightened. In the first 
stage of labor, if the membranes are unruptured and the patient is 
exhausted, no attempt should be made to excite uterine action, but rest 
and sleep should be secured by means of chloral, grs. xx, repeated if 
necessary, or a hypodermic of morphia, gr. J- to ^. Chloral is generally 
preferable to morphia, because it does not arrest the progress of labor. 
Opium is apt to stop or weaken the pains, and should be used only when 
the suffering is too great to be relieved by chloral. Antipyrine is some- 
times useful when the pain is mainly neuralgic in character. At the 
same time broth, hot milk, gruel, or some other nutritious assimilable 
food should be given to maintain the patient's strength. After a few 
hours' rest strong uterine action generally sets in and labor proceeds 
normally. If the membranes have been long ruptured and further delay 
seems inadvisable or dangerous, coffee, broth, or eggnog may be admin- 
istered, and attempts made to increase the power of uterine contractions. 
Quinine is sometimes of great value, but it must be given in large doses 
to be effectual — not less than 15 grains should be given in two powders 
or cachets, within the space of half an hour. Strychnine hypodermically 
(gr. -g^ to 2V) is very often useful, especially if the heart's action is 
weak. Locally, a copious hot vaginal douche (3 to 4 quarts of boiled 
water at a temperature of 105° to 110° F.) may be given every hour or 
two. Good results have been reported from the introduction of a soft 
bougie into the uterus, as in Krause's method of inducing labor. On 
the Continent a favorite method is to pass a rubber bag (colpeurynter) 
into the vagina and then distend it slowly with water or air. The 
Champetier de Ribes bag, introduced into the uterus, is very useful for 
this purpose, and sometimes changes the character of the pains remarka- 
bly. Hot fomentations to the fundus are employed sometimes to excite 
or increase uterine action. 

It is the custom with some practitioners to rupture the membranes 
early in the first stage of the labor for the purpose of hastening de- 
livery. Such practice is not only harmful, but it actually tends to pro- 
long rather than shorten labor, especially when uterine action inclines 
to be weak. As a rule, the membranes should be preserved intact as 



im; PATHOLOGY OF LABOR. 

loiiLC as possible, or at least until dilatation of the cervix is nearly com- 
plete when, however, the uterus is overdistended, as in hydramnios, 

and the contractions are weakened therein-, it is advisable to rupture the 

membranes, even though the os is only partially dilated, in order that 
the tension may he relieved and uterine action stimulated. 

In the second Stage, when further delay is likely to be injurious, labor 
should be terminated as soon as possible. When delay is due to weak 
muscular action, or to some deviation in the uterine axis, a change of 
posture often produces the happiest results. If there is excessive right 
obliquity the patient should be made to lie on the left side; if there is 
anteversion from lax abdominal walls, a binder should be applied and 
the patient should lie on the back. Sometimes uterine action may be 
stimulated very satisfactorily by changing the patient from the lateral to 
the dorsal position and raising the shoulders till she is sitting almost 
upright, or by causing her to get out of bed and walk about, or stand or 
sit for a time. 

Manual pressure applied to the fundus through the abdominal wall is 
a valuable means of intensifying feeble pains and prolonging their effi- 
ciency. The patient should lie in the dorsal position, and pressure 
should be made during a pain in the axis of the brim, much in the same 
way as in the Crede method of expressing the placenta. Schmidt, of 
Moscow, places the patient in the extreme lithotomy position during this 
manipulation. Roughness should be avoided, and care should be taken 
not to compress or injure the ovaries. 

Recently the use of ergot has been warmly recommended to increase 
the force of the pains in the second stage of labor. It is possible that 
such practice may be serviceable in exceptional cases, but ergot is more 
or less dangerous before the birth of the child, and its use cannot be 
recommended unless for some special indication. It should be given 
cautiously, a dose of t^x to xv of the fluid extract hourly for two or 
three hours usually being sufficient. 

Operative interference (forceps, version, etc.) may be required to ter- 
minate labor. No doubt much harm may be done by the rash and indis- 
criminate use of forceps; but it is possible to err in the other extreme; 
indeed, it is quite likely that more lives have been lost and more serious 
injury has been done by deferring the use of forceps too long in linger- 
ing labor than by operating too early. 

(c) Spasm and Irregularity — Rigid Os and Cervix — Tetanus 

Uteri. 

The uterine contractions may be abnormally painful, and whether 
strong or weak they may be faulty in direction, duration, or effect. 
Such spasmodic contractions may be general or partial, and although 
clonic at first, they soon tend to become tonic. The so-called tetanus 
uteri is a condition of general tonic contraction. 

Causes. A uterus rendered irritable by previous endometritis may take 
on spasmodic action after premature rupture of the membranes, especi- 
ally if there is malpresentation or impaction, or if there is undue resist- 
ance, as in pelvic deformity. The tendency to spasmodic action is 
increased by too early use of ergot, by repeated vaginal examinations, 



ANOMALIES OF THE MECHANISM. 407 

or by rough manipulations, as in attempts to dilate the cervix forcibly 
or to deliver by forceps or version through a partially dilated cervix. 
In the third stage of labor, attempts to deliver the placenta by traction 
upon the cord may cause a similar condition. When the spasmodic 
action does not involve the whole uterus the structures most commonly 
affected are the circular fibres around the external and internal os and 
the orifices of the Fallopain tubes, and then a sort of spasmodic stricture 
is produced. Stricture and tetanus uteri vary only in degree; the former 
readily passes into the latter, followed by marked constitutional disturb- 
ance, if the spasm is not promptly relieved. 

Diagnosis. If the fibres of the os and cervix are chiefly involved, the 
os is sensitive to touch and feels to the examining finger like a tensely 
stretched ring; it may remain unchanged for hours, in spite of strong 
uterine action. The lower uterine segment and the cervix may thin out 
and become stretched over the presenting part, yet the os does not yield. 
When there is general tonic spasm the uterus does not relax, but remains 
in a state of continuous contraction, and through the abdominal wall 
feels as hard as a board. If it becomes moulded about the head, elbows, 
and knees of the foetus, and assumes an irregular contour, the foetus is 
held gripped in the spasmodic clutch of the uterine fibres, and labor is 
arrested. 

Prognosis. The prognosis is more favorable for mother and child in 
stricture than in tetanus uteri. In the latter the placental circulation 
is seriously disturbed and the child is apt to perish soon from asphyxia. 
After a time the uterus becomes so unevenly thinned and stretched that 
it is likely to rupture or to be injured and lacerated during attempts to 
effect delivery. 

Treatment. Whenever spasmodic action of the uterus exists, even in 
slight degree, frequent vaginal examinations and rough manipulations 
should be avoided and ergot should not be given. In mild cases and in 
the early stages generally, spasm may be relieved by the internal admin- 
istration of chloral (gr. xx, not more than three doses being given), or by 
a hypodermic injection of morphia. Locally much relief is obtained by a 
hot sitz bath and copious hot vaginal douches. If these measures fail, chlo- 
roform should be administered at once and continued till spasm is relieved. 
Unless in cases of extreme urgency, delivery by forceps or version should 
not be attempted until the os has become well dilated and uterine spasm 
has relaxed, otherwise so much force may be required to effect delivery 
that serious injury may be done to both mother and child. If the os is 
rigid and operation is urgently demanded, manual dilatation under chlo- 
roform should be tried, or a Champetier de Ribes bag may be used ; if these 
measures fail, multiple incisions should be made in the os. When the 
child is dead, or cannot be delivered alive, embryotomy should be per- 
formed. In extreme cases Caesarean section may be required. Under 
no circumstances is it wise to resort to accouchement force in such cases. 
Under proper management, tetanus uteri should not be allowed to de- 
velop. Even after delivery has been effected all danger is not over : 
severe bruising and laceration may have taken place, and the patient 
may suffer subsequently from pressure-fistula?, pelvic exudations and 
inflammations, or from septicaemia. 

Some obstetricians report considerable success in the treatment of rigid 



408 PAT&OLOQ F OF LABOR, 

oe from tlif use of cocaine and atropine. The os is painted with a 2 per 
cent, solution of cocaine, or a cocaine suppository La placed in the cervi- 
cal canal, or a hypodermic injection of atropine (gr. ,'„ ) is made into the 
rigid cervix. 

Some writers describe a variety of cervical spasm in which the cervix 
contracts tightly about the neck of the child after the head lias passed. 
This condition, however, seems to be an elastic rather than a spasmodic 
contraction of the cervix, which continues if the shoulders are very large 
and the uterus is lacking in expulsive power. In most cases it may 
he overcome readily by stretching the contracting ring with the fingers 
while strong downward pressure is made upon the fundus. 



. 



CHAPTEK XX. 

ANOMALIES OF THE MECHANISM.— Continued. 
2. ANOMALIES OF THE PASSAGES. 

A. Hard Parts — Pelvic Deformities. 

Under this heading are included all variations from the normal type 
of bony pilvis. The great majority of these anomalies are of the nature 
of contractions, which make labor a difficult or dangerous process for 
the mother, the child, or for both, and which generally call for some form 
of artificial delivery. The pelvis may be contracted in any or all of its 
diameters, out as the most serious forms are those in which the brim is 
affected, it ic very common to use the term " contracted" as referring to 
these alone. In such a sense it is employed in this chapter, unless other- 
wise indicated. 

Contracted Delves may influence the position of the uterus during 
pregnancy. Taus, in the early months marked contraction of the pelvic 
inlet may cause the growing organ to become retroverted, a condition 
which may be followed by incarceration in the pelvis. In the late 
months the uterus is higher than normal, the foetal head not being able 
to sink within the pelvic cavity. The abdomen is rendered unduly prom- 
inent ; pendulous belly is often marked; the long axis of the uterus being 
directed forward or to one or the other side. 

Contracted pelves also influence the presentation and position of the 
foetus, malpresentations and malpositions being about three times as fre- 
quent as in normal pelves. Thus a vertex presentation may be changed 
to a brow, face, or transverse. When the breech presents the knees or 
feet are apt to descend. The cord is also apt to prolapse into the lower 
pole of the uterus. These malconditions are favored by multiparity, 
owing to the increased relaxation of the uterine and abdominal walls. 

But it is in labor that the most marked effects of contracted pelves 
are seen. At the beginning of the first stage the presenting part is 
higher than in the normal condition, and it does not fit well into the lower 
pole of the uterus. The cervix and lower uterine segment hang loosely 
at or above the brim. The liquor amnii is driven downward, and there 
is a tendency to the protrusion of the bag of membranes through the 
slowly dilating cervix as a sausage-shaped mass. Frequently the bag 
ruptures early, the uterus being drained of the liquor amnii. If the 
contraction be not too great to allow the foetus to be born, labor may 
continue, being prolonged and painful, the cervix dilating slowly, and 
the foetus born dead, the head being much altered by moulding, some- 
times with fractures of its bones. If the labor be too prolonged in such 
a case, or if the contraction be too great to allow the foetus to descend at 
all, the mother may become completely exhausted, and labor may cease 
for a time, or excessive thinning and stretching of the lower uterine 
segment may continue until it ruptures, alone or along with the cervix 
and vaginal wall; sometimes the uterus may be torn from the vagina. 

(409) 



410 PATHOLOGY OF LABOR 

In any oase there is apt to be braising of the soft parte from prolonged 
pressure of the head, and this may be followed by sloughing. 

It is thus evident that the risks to the mother are varied and serious. 
Hie life of the foetus is also greatly endangered, owing to pressure on 
the head, prolapse of the eord, delay in delivery, or to complications 
arising from operative measures necessary to the extraction of the foetus. 

Frequency. Deformed pelves are much more frequent in the Old World 
than in the New. In Europe considerable variations are found in the 
statistics of different observers. Winckel, while believing that 10 to 15 
percent, of child-bearing German women have contracted pelves, thinks 
that in only 5 per cent, is the obstruction serious enough to be noticed. 
In Marburg 20.3 percent, of the cases had deformities; in Gottingen, 
22 percent.; in Prague, 16 percent.; in Rostock, 5 per cent.; in Dres- 
den, 2.8 per cent., and in Munich, 9.5 percent. 

These differences are probably partly accounted for by the absence of 
a common standard of comparison. Thus, undoubtedly, some observers 
have neglected the minor degrees of contraction, considering only those 
capable of causing the most serious trouble. Statistics vary also accord- 
ing to the expertness or fitness of different observers in recognizing 
deformities. Then there are variations according to geographical situa- 
tion, the nature and extent of which are not yet clearly explained; this 
is made evident by a comparison of statistics from the different German 
States. 

As regards America, there is no extensive series of statistics by which 
we can form an exact idea as to the frequency of deformed pelves. It 
may be stated generally that they are much less frequent among native- 
born women than in those of European birth. Reynolds found that in 
the Boston Lying-in Hospital they occurred in 2 per cent, of native-born, 
and in 6 per cent, of foreign-born women. Lusk has reported that 
among native Americans the rachitic pelvis is extraordinarily rare, and 
that the prevailing types of contracted pelvis are the justo-minor and 
those secondary to spinal deformity. Some authorities believe that in 
the older and more densely crowded centres in America deformities are 
more common than in native women living elsewhere. 

Diagnosis of Anomalies of the Hard Pelvis in General. Three lines of 
investigation open to the obstetrician for determining the condition of a 
woman' s pelvis : 

1. A careful study of the history of her previous health and labors, 
and a thorough examination of her physical condition; 

2. The study of the mechanism of labor itself; 

3. Evidence may be gained from the condition of the child's head 
after delivery. 

The latter two subjects will be considered with the individual pelves. 
In this section attention will be directed alone to the first heading. 

In examining a woman her previous history should be inquired into. 
If she had suffered from rickets in childhood there would be a history 
of late dentition, irritability, bad digestion, restlessness and perspiration 
at night, late closure of the anterior fontanelle. She may have had bend- 
ing of the long bones or spine, square head, pigeon-breast, rosary ribs, 
enlarged ends of long bones, and she may be of short stature. 

Various deformities of the pelvis may be associated with rickets — 



ANOMALIES OF THE PASSAGES. 411 

e. g., the rachitic generally contracted, the rachitic infantile, the rachitic 
flat, the scolio-rachitic, the kypho-scolio-rachitic, and the rachitic rostrate 
( pseudo-malacosteon rachitic). 

The patient may have suffered from osteomalacia, in which case she 
would probably give a history of poverty, overwork, and exposure to 
cold and wet under unfavorable conditions of life, the disease having 
begun in a former pregnancy or lactation-period, with dull or aching 
pains in the limbs, back, and pelvis, worse on movement. 

Tuberculosis may have affected her in one or other lower extremity, 
in the hip, or sacro-iliac joint, leading to a simple oblique contraction of 
the pelvis ; or it may have occurred in the spine, giving rise to kyphosis, 
which secondarily may affect the pelvis. 

The patient may have suffered from accident to a limb, resulting in 
shortening, dislocation, weakening, or amputation, secondarily leading to 
a single oblique contraction of the pelvis ; or injury may have dislocated 
the lumbar vertebrae from the sacrum, causing the condition of spondy- 
lolisthesis. 

Possibly the patient may give a history of a weakly early life, asso- 
ciated, however, with no special disease. Such a condition may be 
associated with a flattening of the pelvis or with some maldevelopment. 
Or she may have been born with a congenital dislocation of one or both 
hips, or with spondylolisthesis. 

But the most satisfactory information is derived from the physical 
examination of the pelvis — pelvimetry. A series of measurements are 
to be made in the following systematic manner. 

(a.) External Measurements. 

1. Antero-posterior. An important antero-posterior measurement is 
that known as the "External Conjugate of Baudelocque." To determine 

Fig. 252. 




Baudelocque's pelvimeter. 



412 



PATHOLOGY OF LABOR. 



this, the patient is placed on her Bide, her hips being carefully exposed 
and the clothes tucked out of the way. The physician stands behind the 

patient, looking toward her head. He then takes a pair of calipers, 
the SO-called pelvimeter, and holds a rod in each hand, the tip of the 
index-finger being on each knob. The knob of one rod is placed in the 
depression just below the spine of the last Lumbar vertebra, and the other 

on the skin of the inons veneris in front of the upper part of the sym- 
physis. The rods are then fixed in position, a screw being turned by an 
assistant, and the measurement is read on the scale attached to the instru- 
ment 

The externa] conjugate in a normal adult should measure at least 7 j 
inches. Allowing 3J inches for the average thickness of bones and soft 
tissues, the length of the conjugata vera is in the normal condition 4 
inches. If the measurement be less than 7J inches there is some antero- 
posterior contraction of the brim in a large number of cases. If it be 
more than 7 J inches contraction is very rare. 

There is another manner in which the vera can be made out in a 
thin non-pregnant woman, or in a pregnant woman whose uterus has not 



Fig. 253. 




Measuring the conjugate in a rachitic woman by external application of the hands. 



risen above the brim, viz., by placing the hand on the hypogastrium and 
pressing the abdominal wall with the tips of the straightened fingers 
against the promontory; the thickness of the abdominal wall and pubes 
can be fairly correctly estimated and allowed for. 

2. Transverse. It is impossible to estimate the transverse diameter of 
the true pelvis accurately. The following measurements are usually 
made : 

(a) Between the anterior superior iliac spines, 9 J to 10 J inches. 

(b) Between the widest parts of the iliac crests, 10J to 11 J inches. 

(c) Between the posterior superior iliac spines, 3| inches. 

(d) Between the great trochanters, 11 J to 12J inches. This measure- 
ment is not very reliable, owing to variations in the head, neck, and tro- 
chanter of the femur. If, however, it be less than 11 J inches, transverse 
contraction of the pelvis may be suspected. 

If all these measurements are considerably less than the normal, 
transverse contraction of the pelvis is certain. 

3. Oblique. The measurements made for the purpose of determining 
oblique contractions of the pelvis are given on page 425. 



ANOMALIES OF THE PASSAGES. 



413 



(6.) Internal Measurements. 

For the purpose of determining the size of the pelvic canal the fingers 
alone are sufficient. 

By a careful vaginal examination the wall of the canal may be pretty 
thoroughly examined. A good general idea of the capacity of the canal 



Fig. 254. 




Internal pelvimetry. Measuring the diagonal conjugate with the hands. . 

may be made out, projections can be felt, anchylosis of the coccyx can be 
determined, and the size of the outlet estimated. The height of the 
symphysis can also be made out. Certain special measurements must, 
however, be made : 

1. The diagonal conjugate — i. e., from the promontory to the subpubic 
ligament. In determining this the patient should be placed in the lith- 
otomy position, a ad the first two fingers, extended, should be passed up 
the vagina until the tip of the second finger touches the promontory. 
The radial side of the hand is then raised until it presses against the sub- 
pubic ligament, and a mark is made at this point on the hand, which is 
then withdrawn. With a pelvimeter the distance between this mark and 
the tip of the second finger is then taken. This is the length of the 
diagonal conjugate. In the normal pelvis it is J to f inch greater than 
the true conjugate of the brim. The difference between these diameters 
varies in different pelves, according to the height of the symphysis, the 
height of the promontory, and the angle between the vertical axis of the 
symphysis and the true conjugate. 

Thus, in the rickety flat pelvis, where the height of the symphysis is 
greater than normal, and the angle between its axis and the vera is also 
greater, the difference between the diameters is greater than in the normal 
pelvis. 

When the height of the symphysis is more than 1 J inches, about f 
inch should be deducted from the diagonal conjugate. 

2. LbhleinJ 8 measurement, from the subpubic ligament to the upper 
anterior angle of the great sacro-sciatic notch. This is said to be nor- 
mally f inch, 2 cm., less than the transverse diameter of the brim. 

3. Hirst's measurement, from the promontory to the upper outer edge 
of the symphysis. This is taken with a special pelvimeter consisting of 



414 PATHOLOGY OF LABOR. 

a Long straight rod which is passed up the vagina to touch the promon- 
tory, and a BOOrl curved rod, which touches the front of the symphysis. 
When the instrument La in position its rods arc tightened and then 

removed, the distance between the points of the rods being measured. 
The thickness of the upper part- of the symphysis IS then measured 
with a small pair of calipers and is subtracted from the first obtained 
Length, in order to give the length of the true conjugate. 

lu measuring the diagonal conjugate with the linger.-, there mav be 
difficulty in reaching the promontory if the patient strains much, if the 
perineum is rigid, if the pelvis is very deep, or the promontory high or 
far back. The condition of double promontory, viz., that in which the 
junction of the first and second sacral vertebne projects forward, like 
that between the last lumbar and first sacral, may exist and lead to an 
error in estimation; the point nearest the symphysis should always be 
chosen. In these conditions of difficulty the employment of general 
anaesthesia is of great value. 

It is of great importance, also, to measure the conjugate and transverse 
diameters of the outlet. For this purpose special instruments are em- 
ployed by some, but exact information can be obtained w r ith the fingers 
and calipers. 

Classification. 

Various classifications are employed in different countries. It is need- 
less for the student to study the relative merits of these. It is best to 
select one as his basis of study, realizing that no system can satisfy all 
requirements of scientific completeness. The following plan is recom- 
mended: 

I. Pelves normally proportioned but abnormal in size: 

1. Uniformly enlarged (cequabiliter justo -major). 

2. Uniformly contracted (cequabiliter judo-minor). 

II. Pelves with anomalies of size, shape, inclination, or combinations 
of these : 

1. Those with minor developmental peculiarities : (a) Masculine 

(6) shallow, (c) deep, (d) funnel-shaped. 

2. Antero-posteriorly contracted: 
Flat, non-rachitic. 

Flat, rachitic. 

3. Obliquely contracted: 

By imperfect development of one sacral ala (Naegele pelvis). 
By imperfect or abolished use of one limb. 
By lateral spinal curvature. 

4. Transversely contracted: 

By imperfect development of both sacral alse (Robert pelvis). 
By kyphosis of the spine. 

5. Compressed pelvis: 
Malacosteon. 
Pseudo-malacosteon rachitic. 

6. Spondylolisthetic. 

7. Pelvis distorted by injury, tumors, anchylosis of joints. 

8. Deformity due to spinal curvature : 



ANOMALIES OF THE PASSAGES. 



415 



(a) Kyphotic. 
(6) Scoliotic. 

(c) Kyphoscoliotic. 

(d) Lordosis. 



Individual Forms. 



Fig. 255. 



I. Pelves Normally Proportioned, but Abnormal in Size. 

Uniformly Enlarged Pelvis (cequablllter justo-major). This pelvis has 
all the characters of a normal pelvis, except that all the measurements 
are proportionately increased in size. They are found in large, though 
not necessarily in tall, women. 

Influence on Pregnancy and Labor. In pregnancy the uterus 
tends to remain longer in the pelvis than in a normal condition, and, 
consequently, to disturb the bladder and rectal functions. It is gener- 
ally believed that the labor is apt to be a hur- 
ried one. There is a greater tendency to post- 
partum hemorrhage, as Webster has shown, 
owing to the imperfect filling of the pelvis by 
the uterus. 

Uniformly Contracted Pelvis (cequabiliter justo- 
minor). The most common form has the cha- 
racters of a normal female pelvis save that all 
the measurements are proportionately dimin- 
ished. It is found in women slightly under- 
sized, but may also occur in persons of ordinary 
height, or even in tall women. 

Two other varieties are described by many 
authors, viz. , the infantile form, in which, with 
the small size of the bones, many of the fea- 
tures of the early pelvis are retained, and the 
dwarf form, in which the bones are slender and fragile, the cartilaginous 
junctions between the constituents of the ossa innominata being retained. 

Etiology. The causation of this condition is not well known. In 




Diagram showing head un- 
moulded and moulded by labor 
in normal vertex case. 

Black, unmoulded. 

Red, moulded. 



Fig. 256. 




Generally contracted dwarf pelvis. (After Winckel.) 



416 



PATHOLOG Y OF LABOR. 



some oases \i is due to imperfect development — c g my in dwarfs. In 
other cases it may be due to unfavorable hygienic surroundings and had 
nutrition in early life. 

Diagnosis. The diagnosis is based on careful pelvimetry. The justo- 
minor pelvis may easily be mistaken for a rachitic pelvis. 

Fig. 257. 





Diagram showing difference between normal and justo-minor pelvis on vertical mesial section. 
Black, normal. Red, justo-minor. 

Influence on Labor. If the contraction is not too great to allow 
the foetus to be born, the labor takes place by a definite mechanism which 

Fig. 258. 




Infantile pelvis. (After Ahi.fi eld.) 

resembles that in a normal pelvis, the flexion, however, being much more 
marked. In the normal pelvis flexion occurs so that the suboccipito- 



ANOMALIES OF THE PASSAGES. 



417 



Fig. 259. 




bregmatic diameter, drawn to the anterior angle of the bregma, comes 

into relation with the brim. In the justo-minor pelvis a shorter posterior 

suboccipito-bregmatic diameter comes into relation 

with the brim as a result of the increased flexion, 

depending upon the increased resistance with which 

the head meets. On examination, during labor, 

the tip of the occiput or even the external occipital 

protuberance (inion) may be felt in the centre of 

the canal. 

After flexion, internal rotation, extension, and 
external rotation occur as normally. 

The labor may be much prolonged. Sometimes 
the pains may cease for a time, owing to the great 
resistance, or to the paralyzing effects due to the 
pressure on the soft parts between the foetal head 
and the bony pelvis. 

Head Moulding. The head is markedly compressed in the sub- 
occipito-bregmatic diameter and elongated in the occipito-mental. In 
profile it has the shape of a sugar-loaf. This is 
all the more marked if a large caput succeda- 
neuni has formed over the tip of the occiput. 

Treatment. When the labor is delayed 
in a justo-minor pelvis, forceps should be 
tried, provided the canal is large enough. 
This method may be employed when the brim 
conjugate is as low as 9.5 cm. 

The forceps is used because it assists the 
natural mechanism — i. e., it allows the head 
to be well flexed. This is especially true of 
the axis-traction variety. 

Turning must not be employed, because the 
head becomes extended thereby, and the arms Diagram showing head un- 
are apt to be displaced upward, greatly in- mou i ded and moulded by labor 

• ^i t/¥» ii p j? i t p inajusto-minorcase. 

creasing the dimculty ot a sate delivery ot ', ._ -. 

,, , "°, ., i ,i -i • Black, unmoulded. 

the head through the brim. Red) moulded. 



Diagram showing outline 
of brim of normal and of 
justo-minor pelvis. 

Black, normal. 

Red, justo-minor. 



Fig. 260. 




II. Pelves with Anomalies of Size, Shape, Inclination, or 
Combinations of These. 



1. Those with Minor Developmental Peculiarities. 

(a) Masculine. Sometimes a woman's pelvis may present all the char- 
acteristics of a male pelvis. 

Delay may be caused in labor either at the brim or outlet. Forceps 
may be required. 

(6) Shallow. This term is applied to a pelvis in which the distance 
from the brim to the outlet is relatively less than in the normal pelvis. 

Labor is not necessarily always easy in this form of pelvis. In the 
high forceps operation, however, there is less difficulty than in the case 
of a deep pelvis. 

27 



lis 



PATHOLOG V OF LABOR. 



(c) Deep. In this pel vie there Lb an abnormal increase in the distance 
from the inlei to the outlet. 

('/) Funnel-shaped. This term is applied to a pelvis in which there is a 
contraction of the pelvis at the outlet antero-posteriorly, transversely, or 

in both these direction-. The canal, in fact, resembles that in the male 

pelvis, and by some authors " male' 1 and "funnel-shaped" are used 
synonymously. 

It must be remembered, however, that a pelvis may he funnel-shaped 
without possessing any other male characteristics. 

DlAGNOSK. The nature of the pelvis is made out by a careful com- 
parison of the outlet and inlet measurements and by a careful examina- 
tion of the pelvic canal. 

Fig. 261. 




Funnel-shaped pelris. (After Winckel.) 

Influence on Labor. The mechanism of labor mayjDe interfered 
with — i. e., flexion may be interrupted, or backward rotation of the 
occiput may occur. The labor is prolonged. The soft parts are unduly 
pressed against the bony wall — e. g., the cervix against the promontory, 
or the bladder against the pubes, and laceration or necrosis may result. 
There is greater risk of rupture of the perineum. 

Treatment. In the lesser degrees of contraction forceps should be 
used Avhen there is delay. In more marked contractions, embryulcia, 
symphyseotomy, or Cesarean section may be required. 

2. Antero-posteriorly Contracted, or Flat Pelves. 

In these the characteristic feature is shortening of the conjugate of 
the brim. 

(a) Flat Non-rachitic, or Simple Flat. This is a common variety in 
Europe, but rare in America. There is an approach of the whole sacrum 
to the pubes, the transverse diameter of the pelvis being, consequently, 
relatively increased. The conjugate in this form is rarely below three 
inches. 

Etiology. The causes are not clearly known. Hard work in youth, 
a weakly condition of body, too early walking, lifting heavy weights, 
and excessive standing on the feet are believed to be important factors 
in causing the deformity. Sometimes the condition is congenital. 



ANOMALIES OF THE PASSAGES. 



419 



Diagnosis. There may be nothing diagnostic in the build of the 
individual. It may be found in large and small women. The relation- 
ship between the intercristal and interspiuous diameters may be scarcely 



Fig. 262. 




Fig. 263. 



Flat non-rachitic pelvis. (After Kleinwachter.) 

altered from the normal, or not at all. There are no signs of rickets. 
The diagnosis is based upon the shortening of the external and diagonal 
conjugates. 

(6) Flat rachitic. This is the most important form of flat pelvis. The 
following description may be regarded as that of a typical specimen. 

In general, the pelvis is heavier than a normal 
one of corresponding size, owing to the increased 
condensation in the bones as a result of the dis- 
ease. The bones are thicker, firmer, and some- 
what smaller. The sacrum, however, is wider than 
normal. 

The iliac crests do not possess the normal curve. 
They tend to become more or less everted at their 
anterior ends, so that the interspiuous diameter 
approaches, equals, or is greater than the intercris- 
tal. The direction of the crests is partly due to 
the arrest of development, as the normal curve of 
the crests only appears after the age at which rickets 
occurs. The ilia are partly flattened also by the dragging of the sacro- 
iliac ligaments and the sartorii and glutei muscles. The iliac fossae 
are not as distinctly hollowed, nor the iliac wings as expanded as in the 
normal pelvis; the fossae look more directly forward. The wings are 
more stumpy than normal. 

The brim is kidney-shaped, not heart-shaped, as in the normal pelvis. 




Diagram showing outline 
of brim of normal and of 
flat rachitic pelvis. 
Black, normal, Red, flat. 



120 



PATHOLOGY OF LABOR. 



Fig. 204 



The conjugate vera is Less than the normal four inches, and the trans- 
verse 18 both relatively and absolutely increased. 

The cavity of the pelvis is roomy and wider than in the normal state. 
The anterior Burface of the sacrum is not concave from side to side, as 

in the n »nnal condition, but, owing to the bulging forward of the bodies, 
it is cither tlat or convex. 

The outlet has a widened transverse; the conjugate is normal or 
slightly increased. 

The pubic arch is wide and the acetabula are directed more forward 
than in the normal state. 

On vertical mesial section the symphysis is seen to be deeper than 
normal, its long axis not being parallel with that of the upper part of 

the sacrum, as in the normal condition, but 
tending to converge toward it above the 
brim. The main extent of the sacram is 
straight from above downward. Usually a 
sharp bend occurs about the fourth vertebra. 
The relation of the conjugata vera to the 
conjugata diagonalis is not the same as in 
the normal pelvis. In the latter the differ- 
ence between them is about half an inch. In 
the rickety the difference is greater, three- 
qnarters of an inch or more, owing to two 
factors, viz., the increased depth of the sym- 
physis and the divergence of the lower 
margin of the symphysis from the normal 
position. 

Etiology. It is evident that these 
changes may be grouped around one main 
feature — the sinking of the promontory. 
Rickets causes in the early stages a soften- 
ing of the bones, and if, in this condition, 
the body be kept to a considerable extent in 
the erect or sitting posture, its weight will tend to push the promontory 
downward and forward. The lower part of the sacrum, with the coccyx, 
tends to move upward and backward, but it cannot do so to any appre- 
ciable extent, on account of being held by the strong ligaments attached 
to it. Consequently, a sharp bend is produced about the fourth sacral 
vertebra. In addition to the weight of the body, the action of the mus- 
cles attached to the pelvis may help to bring about the deformity. The 
separation of the ischial tuberosities is due to the widening of the pelvis 
and to the action of the adductor and rotator muscles of the thigh. 
This will be increased by the weight of the body acting in the sitting 
posture. 

Rickets usually develops in the early years of life. It may occur in 
utero, and the foetus may be born with the pelvis somewhat altered; in 
the latter case probably the alterations are brought about by muscular 
action mainly. Great variations are produced by rickets, depending 
upon the date of its appearance, its severity, the habits of the child, etc. 
We have described the typical flat rickety pelvis. In some cases, where 
there is such a degree of disease as to permanently interfere with bone- 




Diagram showing difference be- 
tween normal and rachitic pelvis on 
vertical mesial section. 

Black, normal. Red, rachitic. 



ANOMALIES OF THE PASSAGES. 



421 



Fig. 265. 



development, a condition of pelvis known as the rachitic generally con- 
tracted pelvis may be induced; or a rachitic infantile pelvis may result, in 
which there is a narrow transverse diameter, relatively to the conjugate. 
Sometimes the pubes may be bent inward toward the promontory by 
muscular action, causing the brim to have a figure-of-eight shape. When 
the disease begins after the child has learned to walk and run, the weight 
of the body is transmitted to the legs, and, owing to counter-pressure at 
the acetabula, they may be forced inward, thus giving rise to the rachitic 
rostrate, or pseudo-malacosteon pelvis. 

When lateral curvature of the spine is present as a result of the rick- 
ets, the scolio-rachitic obliquely contracted pelvis is the result. 

Diagnosis. The diagnosis of a rachitic pelvis is formed from study- 
ing the woman's history, by her appearance, by examination and meas- 
urement of her pelvis. A woman who 
has suffered from the disease in childhood 
is usually undersized, with square head, 
flat nose, pigeon-breast, and with curved 
long bones whose ends are enlarged. 
When she lies on a flat surface, lumbar 
lordosis may be well marked. 

By the pelvimeter the normal relation- 
ship between the interspinous and inter- 
cristal diameters is found to be altered, 
as already indicated. The external con- 
jugate of Baudelocque is less than normal. 
The diagonal conjugate is less. The dif- 
ference between the diagonal and true 
conjugates is greater than in the normal 
pelvis. 

Sometimes a condition of double prom- 
ontory exists, owing to the prominence 
of the junction of the first and second 
sacral vertebrae. In such a case the con- 
jugates should be measured from the pro- 
jection nearest the symphysis. Some- 
times, on account of marked lordosis, the 
lumbar vertebra? may be nearer the sym- 
physis than the real promontory; in this 
case the conjugates should be measured 
from the bony point nearest the symphysis. 

Influence on Pregnancy and La- 
bor. This has already been described 
(vide p. 403). 

Mechanism of Labor in a Flat 
Rachitic Pelvis. Where the foetus can be born, the passage of the 
head through the contracted brim takes place by a distinct and special 
mechanism. 

In the normal pelvis the long diameter of the head lies at the begin- 
ning of labor, as Solayres first showed, in an oblique diameter of the 
brim. In the rachitic pelvis it lies in the transverse. In the normal 
pelvis the head is flexed; in the rachitic it becomes extended — i. e., the 




Pregnancy in a woman with a flat 
rachitic pelvis. The condition of pen- 
dulous belly is shown. 



422 PATHOLOQ V OF LABOR 

sincipital end is Lowered. In the normal pelvis the Sagittal suture passes 

through the central point of the inlet; in the rickety pelvis, as Naegele 

first BDOWed, the BUture IS nearer the posterior wall, or, in other words, 

the occipitofrontal plane of the head is oblique to the plane of the brim. 

A.g the Becond Btage of labor proceeds extension of the head increases, 

tin- sinciput dipping, the occipital end of the head being well against the 
side of the brim, the short, bitemporal diameter being in relation to 
the conjugate vera. 

At the same time a movement takes place, known as the " rounding 
of the promontory." The head turns on its antero-posterior axis, so 
that the sagittal suture, instead of being near the promontory, approaches 
the symphysis; it then turns back again, so that the suture is nearer the 
back wall, now, however, being below the promontory. The head has, 
as it were, dodged round the promontory. 

After the passage of the brim there is no obstruction in the true pelvis, 
and the rest of the mechanism may go on normally. Or, owing to the 
width of the transverse diameter of the outlet, the head may be forced 
onward without any special mechanism. 

It is evident that should the head stick before it has passed the brim, 
different presentations may be made out clinically. Thus, a brow or 
face presentation may be found. One parietal bone may present, the 
sagittal suture being near the promontory, or the other parietal bone may 
present, the sagittal suture being near the symphysis. 

Sometimes an altogether different mechanism may be attempted — i. e., 
the head may attempt to get through one-half of the brim by a mechan- 
ism of extreme flexion. This mechanism may also be found in some 
cases of the generally contracted rachitic pelvis. 

Fig. 266. 




Depression of temporal region of skull as a result of delivery through a flat pelvis. 
(After E. Martin.) 

Head Moulding. The characteristic feature is the presence of the 
"promontory mark" — i. e. y a depression in the parietal region which 
is in contact with the promontory during the passage of the brim. 
There is also generally a red mark on the skin, running from this depres- 
sion toward the temple parallel with the coronal suture. Usually the 
parietal bone which was anterior in the pelvis overlaps the other. 

Breech Delivery in a Flat Pelvis. The delivery of the trunk 



ANOMALIES OF THE PASSAGES. 



423 



usually proceeds normally. The arms are more apt to be extended 
upward than in a normal pelvis. The after-coming head enters the brim 
in the transverse diameter. If the brim contraction is slight the head 
may pass through flexed; if great it becomes extended. Often it tends 
to stick above the brim. 

Treatment. For a long period the classical method of treating a 
case in which the head presents has been that of version, providing the 
conditions are favorable. Recently, however, the use of the axis-traction 
forceps has been strongly advocated, mainly by Milne Murray, who 
claims that this method is as favorable to the child as version, and no 
more dangerous to the mother. 



Fig. 267. 



Fig. 268. 





Moulding of head during passage through flat 
rachitic pelvis. 



Diagram showing outline of brim of normal 

Naegele pelvis. 

Black, normal. Red, Naegele. 



Of great assistance in these cases is the employment of Walcher's posi- 
tion. (See Plate XI.) The patient lies across the bed so that her lower 
limbs hang over the edge, the feet not touching the floor. The weight 
of the legs draws the symphysis downward, thus increasing the conju- 
gate of the inlet and correspondingly diminishing that of the outlet. 
As much as one-third of an inch increase in the brim conjugate may be 
gained. 



Fig. 269. 




Singly obliquely contracted pelvis. (After Heckee.) 

A head may be drawn through the brim in this position when it is 
impossible to do so in the left lateral or lithotomy position. It is recom- 
mended that when the head reaches the outlet the legs should be raised 
to make the conjugate of the outlet as long as possible; but as soon as 



■IlM 



PATHOLOQ V of LABOR. 



the head has mainly passed the Bacrum the limbs Bhould be again placed 
in tlu' Walcher position in order to relax the perineum. The raising of 
the Legs is, however, unnecessary; the transverse is usually very wide in 
these cases, and the conjugate not diminished. There will, therefore, be 
little gain, even if the conjugate of the outlet be slightly increased. 

Where delivery is impossible by these methods, embryulcia or Csesa- 
rean Bection have been employed, depending upon the degree of contrac- 
tion; or premature labor has been induced. 

Recently the success of symphyseotomy has led to a very extensive 
abandonment of these latter methods, and there is no doubt that this 
operation will occupy a prominent place in the future. 

The delivery of the after-coming head in breech cases is best effected 
with axis-traction forceps. 

3. Obliquely Contracted Pelves. 

(a) Resulting from Imperfect Development of One Sacral Ala (Naegele 
Pelvis). This pelvis varies somewhat in appearance, according to whether 
part or whole of the sacral ala is wanting. In a well-marked condition 

Fig. 270. 




Singly obliquely contracted pelvis. (After Winckel.) 

the characteristic feature is the single oblique contraction of the brim. 
The latter is of somewhat ovoid shape, the small end of the ovoid 
being at the sacro-iliac joint on the diseased side. The short oblique 
diameter is that of the healthy side— i. e., if the left sacral ala is want- 
ing, the shortened oblique diameter of the brim is the right. 



ANOMALIES OF THE PASSAGES. 425 

The sacrum is narrowed, the sacral wing on one side being partly or 
wholly wanting. Often the sacro-iliac joint on that side is anchylosed. 
The front of the sacrum and the promontory are turned somewhat to the 
diseased side. The os innominatum on this side is pushed upward, 
inward, and backward as a whole. The ischial tuberosity on this side 
is higher than that on the other, the ischial spine being closer to the 
sacrum and projecting more prominently into the pelvic cavity. The 
ilio-pectineal line is often less curved than on the healthy side. The 
subpubic angle is asymmetrical and looks toward the diseased side. The 
acetabulum on the diseased side looks almost directly outward. * 

Etiology. The deficiency in the sacral ala is due either to non- 
development or to some diseased state — e. g., inflammation in early life. 
It may, therefore, be a congenital condition. 

The distortion is aggravated when the child begins to walk, and it is 
easy to understand how the displacement of the os innominatum on the 
diseased side may be brought about. It is important to note that anchy- 
losis of the sacro-iliac joint is not primary in this deformity; it is 
secondary, and is not always present. 

Diagnosis. The diagnosis of the Naegele pelvis, especially where only 
part of the sacral ala is wanting, may be a difficult matter. The follow- 
ing measurements should be made with the pelvimeter : (1) From the 
anterior superior spine of one side to the posterior superior of the oppo- 
site; (2) from the posterior superior spine of one side to the tuber ischii 
of the other; (3) from the spine of the last lumbar vertebra to the anterior 
superior iliac spines of both sides; (4) from the posterior superior spine 
to the great trochanter on the opposite side; (5) from the lower margin 
of the symphysis to the posterior superior iliac spines. 

These right and left measurements must be compared. Normally they 
should be equal or nearly equal. In the marked Naegele pelvis there is 
a considerable difference. Two other measurements may also be made, 
viz., from the middle line of the back to the posterior superior iliac 
spines; from the lower edge of the symphysis to the ischial spines, and 
from these spines to the nearest point of the sacrum. 

Internal examination of the pelvic cavity must be made in order to 
detect the displacement of the lower portion of the os innominatum on 
the diseased side. 

Influence on Labor. If the pelvis is roomy or the deformity 
slight, there may be no delay in the labor. When the contraction affects 
the passage of the head the mechanism by which it attempts to pass the 
brim is the same as in the case of a justo-minor pelvis — i. e., by extreme 
flexion, the antero-posterior diameter of the head being in relation to the 
long oblique diameter of the pelvis. As the head descends it may fail 
to rotate to the front, and may turn to the back. 

In a small pelvis with much contraction delivery is impossible. 

Treatment. The axis-traction forceps should be tried where there 
is delay. Version is recommended by some, but owing to the nature of 
the contraction the former method is most indicated. Embryulcia has 
been used. 

Premature labor may be induced as an alternative method. In extreme 
degrees of contraction Cesarean section should be tried. 



426 



PATHOLOGY OF LABOR. 



Symphyseotomy should not be employed, owing to the anchylosis of 
the Bacro -iliac joint. 

{/)) By Imperfect or Abolished Use of One Limb. This may follow 
unilateral disease of a hip or thigh in early life, if the person has been 

forced to use the sound limb to an excessive amount. The weight of the 
body is transmitted down the sound Limb, and there results a flattening 
or curving inward of the OS innominatum on that side in the region of 
the acetabulum. On the diseased side there is usually some degree of 
compensatory bulging outward of the corresponding portion of bone. 

The same effect is brought about by amputation of one leg or by an 
old-standing dislocation. 

(c) By Lateral Curvature of the Spine (see page 435). 

4. Transversely Contracted Pelves. 

(a) By Imperfect Development of Both Sacral Alae (Robert Pelvis). This 
is a very rare deformity. The conditions are the same as in a Naegele 

Fig. 271. 




Transversely contracted pelvis. (After E. Martin.) 

pelvis, only both sides are affected; hence by some authors the pelvis is 
called u doubly obliquely contracted." In a typical, well-marked speci- 
men there is marked approximation of both ossa innominata. The 



Fig. 272. 




Diagram showing outline of brim of normal and of Robert's transversely contracted pelvis. 
Black, normal. Red, transversely contracted. 



ANOMALIES OF THE PASSAGES. 



427 



sacrum is narrow, and is rectangular, not triangular. It is nearly 
straight in its vertical direction. The ilia extend somewhat behind the 
sacrum, and there is a tendency to shortening of the conjugate of the 
brim. 

In some cases both sides of the sacrum may not be equally maldevel- 
oped. More than the sacral wings may be affected. There is usually 
secondary anchylosis of the sacro-iliac joints. 

Treatment. Csesarean section must be employed. 

(6) By Kyphosis of the Spine (see page 436.) 



Fig. 



5. Compressed Pelves. 

(a) Malacosteon. Various degrees of this condition are met with. In 
a typical well-marked specimen the following points are noticeable. The 

false pelvis is greatly altered in shape. The 
iliac fossae, instead of having the normal 
saucer-like hollowing, are scoop-shaped, ow- 
ing to the marked bending of the iliac 
wings, the anterior superior iliac spines turn- 
ing inward. 

The brim has a characteristic triradiate 
or stellate shape, owing to the approximation 
of the promontory and the acetabula. The 

Fig. 274. 




Diagram showing difference be- 
tween normal and malacosteon pel- 
vis on vertical mesial section. 

Black, normal. 

Red, malacosteon. 




Diagram showing outline of brim of normal and of mala- 
costeon pelvis. 
Black, normal. Red, malacosteon. 



pubic bones are close together, forming a kind of projection or beak. 
Hence this pelvis is often known as the rostrate or beak-shaped pelvis. 
The pubic arch is very narrow. The descending rami may be somewhat 
twisted. The ischial tuberosities are approximated and may be some- 
what bent. The lower end of the sacrum with the coccyx is curved up- 
ward into the pelvic canal. 

Etiology. The deformity is brought about when the pelvis is soft- 
ened by the disease, osteomalacia (mollities ossium). This condition 
usually develops in the puerperium, but may occur in pregnancy. There 
is a removal of the lime salts from the bones. In the softened condition 
of the pelvis it is easy to understand how the weight of the body, the 
resistance of the lower limbs at the acetabulum, and the sitting posture 
may result in a crushing in of the pelvis, as has just been described. 

Diagnosis. The diagnosis is based on the history of the case and on 
external and internal examination of the pelvis. The gait is generally 



428 



PATHOLOQ V OF LABOR. 



peculiar: the body rotato greatly 88 one foot is advanced in front of the 
other. 

I \ i i i i:\< i. ON LABOR. In the softened condition of the hones labor 

may proceed naturally, though there are great dangers to the mother. 



Pig. 276. 




Malacosteon pelvis, seen from above. (After Winckel.) 

In eighty-five cases collected by Litzmann there was a mortality of forty- 
seven. In the hardened condition, natural delivery is, in the great 
majority of cases, impossible 

Fig. 276. 




Malacosteou pelvis seen from front. (After Winckel.) 



Treatment. In the softened condition of the bones forceps and ver- 
sion have been employed to aid delivery. Now, however, in these cases 
it is extremely likely that Cesarean section with removal of the ovaries, 
or Porro's operation, will be employed, because of the curative influence 
which extirpation of the ovaries exerts on the disease. 

When the bones are hard and the deformity fixed, the procedure 
depends upon the degree of contraction. 

Embryulcia may sometimes be employed, but in the great majority of 
cases Cesarean section must be carried out. 

(6) Pseudo-malacosteon Rachitic. This form has already been alluded 
to in connection with rickets. 

The pubis projects as a beak, the acetabula being somewhat pressed 



ANOMALIES OF THE PASSAGES. 



429 



inward. The iliac wings are not scoop-shaped, as in the true malacosteon, 
but are widely separated anteriorly, as in the typical rachitic condition. 
Etiology. This condition is due to rickets (see page 421). 



Fig. 277. 




Pseduo-malacosteon rachitic pelvis. (After Schroeder.) 
Pig. 278. 





Front and back view of woman with moderate degree of spondylolisthesis. (After Winckel.) 

6. Spondylolisthetic Pelvis. 

The characteristic feature in this deformity is the projection of the 
lower lumbar vertebrae into the true pelvis, owing to their downward 



430 



PATHOLOQ F OF LABOR. 



displacement The sacrum is poshed somewhat backward and down- 
ward, and the symphysis rises. Tlu* inclination of the brim is thereby 
greatly Lessened. The conjugate of the pelvis is diminished, varying 
according to the amount of descent of the vertebrae. The iliac crests 
are separated somewhat posteriorly. 

The pelvic outlet is narrowed both transversely and antero-posteriorly. 

E HOLOGY. The causation of this condition is not very clear. Injnrv, 
disease, and developmental errors are believed to l>e predisposing causes. 
Lane believes that extra pressure from above may bring about the con- 
dition, even when the bone is healthy. 

DIAGNOSIS. The history must be carefully studied. There may have 
been an accident — e. g. } a fall, or the woman may have been accustomed 
to carry heavy weights. The height is diminished and the abdomen 
shortened vertically, and it is somewhat pendulous. Seen from behind 
the posterior parts of the iliac crests are very prominent. The articular 
processes of the first sacral and last lumbar vertebra? are very distinct 
below the skin. The ribs are close to the ilia and the flanks are well 
marked. The shoulders are carried well back. When the woman walks 
the footsteps fall in a straight line, the toes not turning outward. Some- 
times she complains of a grating sensation (crepitus) in the lumbar region. 



Fig. 279. 




Spondylolisthetic pelvis. (After E. Martin.') 



Owing to the rotation on the pelvis, the vulvar region is carried for- 
ward. On external examination the symphysis is found to be higher 
than normal, the brim with a lessened inclination, the distance between 
the posterior superior iliac spines increased, and the external conjugate 
of Baudelocque diminished. 

On internal examination the projection of the lumbar vertebrae is dis- 
tinguished, as well as the contracted outlet. The iliac vessels are lower 
than normal, and it may be possible to feel the lower end of the aorta. 



ANOMALIES OF THE PASSAGES. 



431 



The diagonal conjugate must be measured from that point on the lumbar 
projection nearest the symphysis. Owing to the variations in the incli- 
nation of the pelvis and in the degree of deformity, there is no constant 
relationship between the diagonal and true conjugates. The former is 
generally a little greater, but it may be equal to or less than the latter in 
a few cases. 

Influence on Labor. The deformity being of the nature of a 
flattening of the pelvis, the mechanism of labor, providing the head can 
be born, resembles that found in a flat rachitic pelvis. In some cases 




Different views of a woman possessing a spondylolisthetic pelvis. (After Ahlfeld.) 

natural delivery is impossible. Bad ruptures of the pelvic floor are 
common. 

Treatment. Labor is conducted on practically the same lines as 
laid down in connection with rachitic pelves. 

7. Pelves Distorted by Injuries, Disease, Tumors, etc. 

(a) Double Dislocation Backward of the Femora. This rare condition is 
generally congenital. It results in marked rotation forward of the 
sacrum, increased width of the pelvic cavity and outlet, the tuberosities 
of the ischium being dragged outward, upward, and backward. 

(6) Tumors. The commonest are exostoses at the joints — e. g., sacro- 






432 



PATHOLOQ V OF LA Holt. 



iliac, BVmphyais, promontory, sacral. They may be sharp or rounded, 

and vary greatly in size. Tney may also occur on the ileo-pectineal line. 



PlO. 288. 




Bony outgrowth of right half of pelvis. (After Wjnckel.) 

These exostoses may interfere with normal labor, and they may injure 
both maternal and foetal parts. 

Fig. 284. 




Malignant growth of posterior wall of pelvis which necessitated Caesarean section in a case of 

Dr. Cameron. 

Other tumors of the bone may distort the pelvis — e. g., fibroma, sar- 
coma, carcinoma, enchondroma, cysts. Cystic conditions occur in sar- 
coma, enchondroma, and hydatids. Carcinoma is always a secondary 
growth; it may lead to great softening of the bone. 

Treatment. Where the growth is too large to admit of delivery by 
the natural passages, Caesarean section or embryulcia must be performed. 
Symphyseotomy is sometimes performed in these cases, but not where the 



ANOMALIES OF THE PASSAGES. 433 

sacro-iliac joints are involved in the tumor. Enibryulcia is to be espe- 
cially considered if the child be dead. 

(c) Fractures of the Pelvis. Deformity due to this injury is very rare. 
It may result from bad union of the broken bone, from marked callus- 
formation, or from ossification of the joints near the fracture. 

(d) Anchylosis of Joints. This condition may occur in any pelvic joint. 
When at the symphysis, it is not a serious matter as regards labor; but 
it makes symphyseotomy a more difficult operation. 

In the sacro-iliac joints it is a more serious matter. When it occurs 
in early life it may interfere somewhat with the development of the 
adjacent parts of the sacrum and ilium, and so the pelvis may be some- 
what obliquely contracted. This is a rare condition, however. 

The sacro-coccygeal and coccygeal joints may sometimes become an- 
chylosed. More commonly the sacro-coccygeal alone is affected. In 
the former case there may be marked obstruction to labor, and fracture 
of the coccyx may result. 

Fig. 285. 




Split pelvis. (After Kleinwachter. 



(e) Split Pelvis. This is a rare condition, being due to a maldevelop- 
ment in the anterior wall of the pelvis. It is not a cause of delay in 
labor, but is rather apt to be associated with rapid delivery. 

8. Pelvic Deformities Due to Spinal Curvature. 

(a) Kyphotic. This deformity varies greatly, according to the extent 
of the kyphosis. The nearer the sacrum the spinal hump, and the more 
prominent it is, the more marked the changes in the pelvis. Generally 
the kyphosis is in the region of the junction of the dorsal and lumbar 
vertebrae. 

Owing to the spinal curvature the centre of gravity of the body above 
it is thrown forward. Some degree of lordosis is brought about by way 
of compensation, but this is not sufficient, and a rotation of the sacrum 
occurs, so that the upper end is thrown backward and downward. There 
is also a rotation of the ossa innominata upon their antero-posterior axes. 

28 



434 



/' I THOLOQ V OF LA li< HI. 



The characteristic alteration in the pelvis is the change in the brim, 
from the normal heart-shape to an oval, in which the long diameter is 
antero-posterior. This results from the backward movement of the prom- 
ontory, whose prominence may entirely disappear. The Bacrum becomes 
Longer, narrower, and straighter. The posterior superior iliac spine- are 
drawn nearer to each other and the anterior are separated. 

Fig. 286. 




Kyphotic pelvis. (After Kleinwachter. 



The pelvic canal may become markedly funnel-shaped, owing to the 
movement forward of the lower part of the sacrum, and to the approxi- 
mation of the ischial tuberosities; but many variations are found iu the 
degree of contraction. The lower the kyphosis the more will the portion 
of the spine which projects forward tend to interfere with the brim. 



Fig. 287. 



Fig. 2SS. 





Diagram showing outline of brim of normal 
and of kyphotic pelvis. Black, normal. Red, 
kyphotic. 



Diagram showing outline of brim of normal 
and of scoliotic pelvis. Black, normal. Red, 
scoliotic. 



Sometimes the upper part of the sacrum may be affected by the necrosis 
which has caused the kyphosis, and some extra deformity may thus be 
brought about in the sacrum. 

Diagnosis. The diagnosis is easy from examination and from the 



ANOMALIES OF THE PASSAGES. 



435 



woman's history. The condition of the cavity and outlet especially 
must be noted with extreme care. 

Influence on Labor. The obstruction to labor occurs in the lower 
part of the pelvic canal. If the degree of contraction is slight, labor 
may be easy and quick. So frequently may this be the case that a say- 
ing is common in some parts of Europe to the effect that " Hunchbacks 
have easy labors.' ' In a marked degree there is delay, and abnor- 
mal rotation of the head is apt to occur. In a more marked degree of 
contraction birth is impossible. There is special danger of post-partum 
hemorrhage, owing to the imperfect filling of the upper part of the 
pelvis by the uterus. 

Treatment. This varies according to the degree of contraction. 
In slight cases forceps may be used successfully. In worse cases embry- 
ulcia or premature labor may be necessary. In extreme contraction 
Cesarean section is demanded. 

Fig. 289. 




Kyphoscoliotic-rachitic pelvis. (After Ahlfeld 



(b) Scoliotic. When lateral curvature affects the spine its effect on the 
pelvis depends on its situation and extent. The lower the bend in the 
spine and the earlier its occurrence, the more marked will be the pelvic 
deformity. As scoliosis is generally associated with rachitis, the scoliotic 
pelvis will show certain changes due to that disease. The special altera- 
tions induced by the spinal condition are as follows : That half of the 
pelvis toward which the convexity of the curvature is directed receives 
an extra amount of the weight of the body. The innominate bone, there- 
fore, on that side tends to be pushed upward, backward, and inward by 
the resistance of the femur. The acetabulum is curved in somewhat 
toward the sacrum, so that the shortest diameter of the brim is that 
between the promontory and the ilio-pectineal eminence, the so-called 



136 



I'ATlIOLOdY OF LABOR. 



Bacro-cotyloid diameter. There Is also some rotation of the lumbar 
vertebrae toward the side of the convexity. If there is much rachitis 
the promontory may be well forward, the sacral wing on the side of the 
spinal convexity being prominent. Thus the marked deformity is seen 
to be on the Bide of the convexity. 

I \ri.i rv i: on LABOR. When only slight degrees of deformity exist 
the child is horn by the mechanism observed in the case of the rachitic 
pelvis. It' the deformity be more marked, one-half of the pelvis, viz., 
that on the side of the convexity, is of no use, and the head may attempt 
to pas- the Larger part of the brim by a mechanism like that seen in a 
universally contracted pelvis. Embryulcia has been employed in some of 
these cases. But, practically, in all cases where deformity is at all 
marked, Cesarean section is indicated. 

(c) Kyphoscoliotic. Rachitis may cause both kyphosis and scoliosis in 
the same woman. If both are situated low in the spine the pelvis may 



Fig. 290. 



Fig. 291. 








Views of a woman with kyphoscolio-rachitic pelvis. (After Martin and Fassbender.) 



show certain characteristics due to both these conditions. Generally the 
kyphosis is situated high in the dorsal region, and is compensated for by 
a lumbar lordosis, so that the pelvis is not affected by the kyphotic 
curvature. 

(d) Lordosis. Primary lordosis is so rare a condition that no notice 



ANOMALIES OF THE PASSAGES. 437 

need be taken of it in this connection. It is usually secondary to spinal 
disease or to pelvic deformity. 

If low down in the spine it may interfere with the uterus in pregnancy 
and with the entrance of the child in the brim during labor. 



B. Soft Parts. 
1. Uterus. 

Developmental Anomalies. 

When labor takes place in the case of a unicornate uterus there are 
apt to be nialpresentations and positions, mainly owiug to the inclination 
of the long axis of the cornu to the pelvic canal. 

In the case of pregnancy in one horn of a bicornate uterus the same 
tendency exists. Here also labor may be obstructed by the recto-vesical 
ligament which runs between the cornua. Where both horns are preg- 
nant obstruction is likely to occur from jamming together of the twins. 

In the case of a pregnancy in one half of a septate uterus, the unim- 
pregnated half may act as a mechanical obstruction or the septum may 
do this. 

In all these cases the labor pains may often be weak, short, and ineffi- 
cient. Rupture of the uterus may occur. Severe post-partum hemor- 
rhage may result. 

Treatment. It may be necessary to assist delivery by version or 
forceps. In such cases the greatest care should be used in order that 
the uterine wall be not ruptured. Version should be employed as little 
as possible. Embryulcia or Cesarean section may be necessary some- 
times. When a septum is an obstruction it may be cut through. 

When pregnancy occurs in the rudimentary horn of a bicornate uterus, 
the case is very grave and must be treated as one of tubal gestation. 

Atresia of the Cervix. 

This is acquired after conception, usually from the use of escharotics, 
and is seldom complete. Generally a dimple exists at the site of the os 
externum. If the condition be not relieved rupture of the uterus will 
take place. 

Treatment. With a sound a small opening may be made through 
the dimple. Sometimes it is necessary to make a crucial incision. Dila- 
tation usually follows naturally. If there is sharp bleeding, ligatures 
may be necessary. 

Rigidity of the Cervix. 

This condition causes delay in the first stage of labor. It may be 
functional or organic. Functional rigidity is either constitutional — e.g., 
as met in elderly primiparse, or spasmodic. In the latter condition, the 
cervical sphincters do not relax between the pains, and the os externum 
tends to become smaller during the pains. This condition is usually 
associated with inefficient contractions of the body of the uterus. 



138 



PATHOLOGY OF LABOR 



Organic rigidity is due to various causes. Former lacerations may 
have fed to tli< i formation of much cicatricial tissue in the cervix, or this 

condition niav BUCCeed operative procedures. 

Syphilitic changes or new growths sometimes cause rigidity. 



Pro. ■■:>-. 




Stenosis of the cervix uteri obstructing labor. (Alter Jextzer.) 



Treatment. In the constitutional, spasmodic, and inflammatory vari- 
eties, hot douches, frequently given, are serviceable. Chloral, morphia 
suppositories, or large doses of opium in pills may be administered. Large 
doses of chloral are to be preferred, because this drug causes dilatation 
painlessly without interfering with the pains; morphia tends to suspend 
the pains. If the patient be exhausted chloroform may be given, and a 
hypodermic of morphia to induce sleep for a few hours. 

It may be necessary to assist dilatation by separating the membranes 
from the lower uterine segment as much as possible and by pressing the 
lips of the cervix apart with the fingers. Rubber dilators, e. g., Barnes's 
or Champetier de Ribes's, are valuable when the other methods fail. 

Sometimes several incisions, one-half inch deep, must be made in the 
These should immediately precede artificial delivery. 



cervix. 



Impaction of the Cervix. 

In the case of rigid cervix, hypertrophy of the cervix, or in pendulous 
belly, where the os externum is directed to the back, the anterior lip may 
be caught between the head and the pubes, and, becoming swollen and 
oedematous, may impede labor, or, after labor, may slough. In these 



ANOMALIES OF THE PASSAGES. 



439 



cases attempts should be made to push the cervix up between the pains. 
When this is impossible, it is best to draw the head through with forceps 
or to make incisions in the cervix. 

Malpositions of the Uterus. 

Anteversion. When there is marked anteversion in pendulous belly, 
or as a result of separated recti, the uterine force may be so badly directed 
that dilatation takes place very slowly. 

Treatment. The patient is kept on her back, an abdominal binder 
being used to hold the uterus in position. 

Hernia. A pregnant uterus may fall into an umbilical hernia or into 
a ventral hernia following a laparotomy. Sometimes an inguinal hernia 
may contain a pregnant uterus. 

Fig. 293. 




Retroflexion of the gravid uterus. (After Schatz.) 

Treatment. The dorsal position and the binder are employed to 
keep the uterine axis properly directed. In the case of an inguinal 
hernia the child may be delivered by version, and the uterus afterward 
withdrawn from the hernia. But it is probably best to open the hernial 
sac, removing the foetus from the womb and amputating the latter. This 
condition is usually found with a unicornate or bicornate uterus. 



440 



PATHOLOGY OF LA Hon. 



Latero-version. Marked tilting of the fundus to one or other side may 
sometimes occur. The patient should be placed on the side toward which 
the fundus is directed, and a pillow should be put under that side of the 
belly daring labor. 

Sacculation. Where a retroflexion of the gravid uterus has occurred 
in the early months, the pregnancy having advanced to term, there may 
he formed a kind of diverticulum behind the cervix, the latter being 
usually above the brim against the abdominal wall. The posterior vagina] 
wall is markedly bulged downward and forward, and the festal parts may 
he so easily felt as to BUggest an ectopic gestation; or the projecting 
vagina may he mistaken for a bag of membranes. 

TREATMENT. The cervix should be dilated artificially and version 
performed. It may be necessary sometimes to perform ( laesarean section. 

Prolapsus Uteri. Complete prolapse of the pregnant uterus is un- 
known. Various degrees of partial prolapse have been met with. 

Often when pains set in the prolapsed portion is drawn up. But if 
the cervix be rigid or much hypertrophied, this does not happen, and 
the prolapsed portion may become oedematous, and, consequently, more 
pronounced. 

Treatment. See " Impaction of the Cervix.' ' 



New Growths of the Uterus. 

1. Fibromyoma. Fibromyomata are not common causes of trouble in 
labor. It is impossible accurately to group the disturbances which occur 
in relation to the various forms of tumor met with, viz., submucous, sub- 
peritoneal, and interstitial. 

Fig. 294. 




tfec/a/rf 



Myoma uteri complicating pregnancy. (After Spiegelberg.) 

The most dangerous as regards labor are those in the region of the 
cervix. These may lead to malpresentations and positions of the foetus, 



ANOMALIES OF THE PASSAGES. 441 

to obstruction in labor, to prolapse of the cord, to adherent placenta, and 
to post-part urn hemorrhage. Labor pains may be very irregular, often 
inefficient; sometimes a tetanic condition is met with. Laceration of 
the uterus may occur. Contusions and fractures of the foetal skull may 
be caused. Death may occur in some cases if interference be not carried 
out. 

In the puerperium there is increased risk of inflammation and septic 
infection, or, in the case of a submucous tumor, of necrosis. 

Sometimes the contractions of the uterus may displace above the brim 
a small tumor which had lain below it on the anterior wall. 

Spontaneous enucleation of a submucous fibroid may occur during or 
immediately after delivery. 

Diagnosis. The diagnosis is not, as a rule, difficult, save when the 
fibroid is on the posterior wall or projecting into the cavity of the uterus. 
When they can be felt they are generally easily recognized. They may 
be mistaken for parts of the foetus, for twins, or for portions of placenta. 

Treatment. In some cases of fibroid — e. g., subperitoneal ones high 
up in the body — the labor may go on perfectly naturally. In cases where 
there are several small fibroids or a large one high up in the wall, the 
pains may be weak and labor prolonged. In such a case version or for- 
ceps may be employed. Interference should be carried out early, because 
the risks to the mother are greater the longer the delay. 

AY hen a small tumor is felt so low down as to be a source of obstruction, 
it should be carefully examined, in order that it may be known whether 
or not it may be pushed upward. Attempts may be made to push the 
tumor up, the patient being in the lateral, dorsal, or genupectoral posture. 
Anaesthesia may be necessary to carry out this procedure. If this is im- 
possible, the further treatment depends on the amount of contraction. 
It may be so slight that delivery by version or forceps may be performed; 
Walcher's position may sometimes assist delivery. If greater, embry- 
ulcia or Cesarean section is necessary. Should such a case be under 
observation during the course of pregnancy, the induction of premature 
labor may sometimes be a safe method of procedure. 

Polypoidal fibroids of the cervix may be removed before or during 
delivery. Xon-pediculated ones of the cervix may be enucleated artifi- 
cially. 

Where a very large fibroid of the body or several small ones cause 
marked obstruction, Cesarean section or Porro's operation should be 
decided upon. 

In all cases in which delivery is effected through the vagina the 
greatest care must be exercised in the treatment of the third stage. The 
placenta may be adherent and may require separation. Hemorrhage 
may be profuse, from the imperfect contraction and retraction of the 
uterus, or from the opening of vessels in the capsule of a submucous 
fibroid. The hot intra-uterine douche must be used, as well as hypo- 
dermic injections of ergotin. The best method of controlling hemor- 
rhage, however, is to pack the uterus and vagina with sterilized iodoform 
gauze. This may be left in situ for three or four days, and then may be 
renewed if necessary. 

If a submucous tumor tends to become enucleated it should be removed 
early, in order to diminish the risk of necrosis and suppuration. 



1 !•_> PATHOLOQ F OF LABOR. 

It b interesting to note thai uterine fibroids often gel smaller and 
sometimes disappear after labor. 

2. Carcinoma of the Cervix. This condition may be found at full time, 
and may l>e a cause of trouble in labor. Sometimes, if the disease be 
early and localized, the labor may go on naturally. If the cancer be 
advanced and in lilt ratine;- surrounding tissues, and the case be left to 
nature, the pains may be intermittent for days, the patient getting weak- 
ened, and the child usually dying. Rupture of the cervix may occur, 
Leading to bad hemorrhage or to sepsis. 

TREATMENT. If the case is observed during early pregnancy in the 
localized state of the new-growth, total extirpation of the uterus by the 
vagina may be carried out. Later in pregnancy premature labor may be 
induced and amputation of the cervix or extirpation of the uterus afterward 
carried out, or abdominal extirpation of the uterus may be performed. 

At full time, when the cervical cancer is not too extensive, some prefer 
to perform embryulcia, if a living child cannot be delivered. Opinion 
is, however, tending more to favor the performance of Cesarean section 
in all cases where the disease is at all marked. But whenever there is 
a chance that the cancer may be entirely removed, Porro's operation 
should be carried out. 

Stenosis of Vagina and Vulva and Rigidity of Tissues. 

Sometimes the vagina may be double, or have longitudinal or trans- 
verse septa. Rarely, it may be markedly atresic. 

Treatment. Septa should be divided. An atresic portion may be 
dilated if it be not too extensive. Incisions may be necessary. But 
sometimes embryulcia or Cesarean section may be indicated. 

The hymen may be a cause of obstruction and may require incision or 
removal. 

The vagina and vulva may be narrow and tough in elderly primiparae, 
in very muscular women, and in conditions of cicatricial contraction after 
previous injury. 

Treatment. Hot douches, emollients, and warm sponges serve some- 
what to soften the parts. Dilatation may be promoted by means of arti- 
ficial dilators — e.g., Barnes's or Champetier de Ribes's bag. 1 If the 
perineum is so rigid that it will not stretch well, and if a rupture is 
feared, episiotomy should be carried out with scissors, a cut being made 
through the edge on each side a short distance from the middle line. 
This procedure saves the risk of a tear into the anus. The cuts can be 
closed after delivery, if they are large. It is to be remembered that 
labor may be expedited in a case of rigid perineum if the patient be 
placed in Walcher's position. 

Where cicatrization of the vagina does not yield to hydrostatic dilata- 
tion, accompanied with superficial incisions sufficient to permit of delivery 
by version or forceps, Csesarean section is necessary. 

Swellings of the Vagina and Vulva. 

Hematoma. This condition may be found in the labia, the perineum, 
or the vaginal walls. Though it mostly occurs after labor, it may be a 

1 These dilators must not be overdistended, lest rupture of the vagina be caused. 



ANOMALIES OF THE PASSAGES. 443 

cause of delay in labor. Sometimes it may form between the delivery 
of the first and second child in the case of twins. If the mass be large 
enough to obstruct delivery, it should be incised and cleared out, to allow 
of the passage of the foetus. Afterward, if there be slight bleeding, the 
cavity should be packed with iodoform gauze. If, however, the hemor- 
rhage be severe, it may be necessary to close the cavity from side to side 
with a series of sutures and to keep up pressure on the surface by means 
of a pad and bandage. In the case of a small mass, delivery may be 
effected by means of forceps, incision not being necessary. 

(Edema of the Vulva. This condition may be due to heart or kidney 
disease, or to delayed labor. The oedematous parts are apt to tear, and 
may become gangrenous afterward. Puncture or incision may be neces- 
sary, but only when absolutely unavoidable, owing to the risk of sepsis 
or gangrene. This procedure must be carried out with strict asepsis. 
Episiotomy may be necessary to save rupture. 

Varicose Veins of Vulva. These very rarely interfere with the passage 
of the head through the vulva. They may rupture or be so bruised as 
to slough afterward. 

Labial Abscess. If this is large enough to obstruct labor it may be 
opened, scraped out, swabbed with iodized phenol, and stuffed with iodo- 
form gauze. 

Solid Tumors of the Vagina and Vulva. Fibromata and fibromyomata 
may occur and may interfere with delivery. The bruising of the tumor 
may lead to after-gangrene. 

Treatment. If these tumors are not recognized until labor comes 
on, it may be possible to remove them by enucleation or by amputation 
of the pedunculated forms. Where this is not considered advisable, for- 
ceps may be used if the vagina is not too much contracted. There is 
danger of causing after-sloughing of tissues if there be a prolonged use 
of the forceps. Rarely embryulcia or Csesarean section may be necessary. 

Cysts. These may obstruct labor. Puncture is usually sufficient to 
promote delivery. A pediculated cyst may be removed easily during 
labor. 

Enterocele. Vaginal enterocele may be either anterior or posterior. 
The latter is most common. The hernial condition may obstruct labor 
when the bowel is distended with gas or with feces. The long-continued 
pressure of the head may lead to a rupture of the sac, or may seriously 
bruise the bowel. 

Treatment. The patient should be placed in the genupectoral posi- 
tion and the hernia reduced. If this is not possible, owing to the low 
position of the presenting part of the foetus, or to adhesions, the child 
should be delivered rapidly with forceps. Should rupture of the sac 
occur the intestines should be cleansed and returned, and a repair opera- 
tion be performed on the posterior vaginal wall. 

If the hernial condition be a very large one, Csesarean section may be 
justifiable. 

Distended Rectum or Colon. Fecal accumulation may delay labor by 
interfering with the powers and by obstructing the passages. The bowel 
must be cleared out with enemata or by repeated flushings by means of 
a funnel and tube. Sometimes it is necessary to scoop out the masses, 
and for this it may be necessary to anaesthetize the patient. 



444 PATHOLOQ V OF L A BOB. 

Sometimes this distention of the rectum may be associated with the 

condition known as anus vaginalis, in which the anus is placed too far 
forward. 

Cancer of the Rectum, it" extensive, may be such an obstruction as to 
lead to ( IflBSareaD section. 

Conditions of THE Bladder. 

Distention. This is a very common cause of delay in labor. The urine 
should be removed with a long, soft catheter. Sometime- this is Impos- 
sible, and suprapubic aspiration must be carried out. 

Cystocele or Colpocystocele. This condition may obstruct labor. It may 
be mistaken for an impacted cervix, for the bag of membranes, for the 
caput suceedaneuni, or for a tumor. 

TREATMENT. The urine should be drawn off, care being taken to 
pass the catheter downward and backward. The prolapsing part should 
be gradually pushed up above the advancing head. Sometimes it is neces- 
sary to deliver the child with forceps, the sacculation being held up by 
an assistant. 

Vesical Calculus. If the calculus be very small, labor may go on nat- 
urally without causing any trouble, but if it is of any size it is apt to be 
very painful, to obstruct delivery, and to lead to injury of bladder and 
vaginal walls. If discovered early in labor it may be pushed above the 
svmphysis and removed after labor, in the case of a small one. Some, 
however, think it best to remove it by dilatation of the urethra. If the 
stone be too large to be removed in this way, it should be extracted 
through a mesial incision in the anterior vaginal wall and base of the 
bladder. After labor the incision can be closed. 

Tumors of Neighboring Structures. 

Ovarian Tumors. Ovarian tumors may complicate labor in various 
ways. If of large size they may interfere with the powers and may 
obstruct the passages. They may also cause malpositions and malpre- 
sentations. Small tumors are serious causes of obstruction when they 
lie in the true pelvis. Labor may lead to rupture of the tumor when it 
is cystic, and this may be followed by intra-peritoneal hemorrhage or 
peritonitis; or the tumor wall may be much bruised and inflammation 
and adhesion may result. Twisted pedicle and occlusion of the bowels 
are sometimes caused. Rupture of uterus, vagina, or rectum may occur. 

Diagnosis. This may be difficult in some cases. The tumor may be 
mistaken for a fibroid or for a blood or inflammatory exudation when it 
is situated within the true pelvis. When it is cystic and fluctuation can 
be made out by vaginal examination, the diagnosis is easier. 

When the tumor is above the brim and is not situated behind the 
uterus it may be felt distinct from the uterus, and may be moved unless 
impacted or fixed by adhesions. The abdomen is exceptionally distended, 
and the condition may be mistaken for hydramnios or twins. However, 
no intermittent contractions occur in the wall of the tumor, and it is thus 
distinguished from the uterine wall. 

Treatment. If the woman has begun labor and the tumor be below 
the brim, an effort should be made to push it into the abdomen, anaesthesia 



ANOMALIES OF THE FCETUS. 445 

being used if necessary. If this fail, some authorities think it best to 
try delivery with forceps, if the obstruction be not too great; or, if this 
fail, to tap the cyst and deliver with forceps, or to employ embryulcia. 
Others reject these measures and recommend Cesarean section along 
with removal of the tumor. 

The objection to vaginal puncture is that it may be followed by danger 
to the peritoneum by escape of the contents, especially if it be a dermoid. 
If the cyst contain many loculi, puncture may do no good. Also, a 
mistake in diagnosis may be made, and a pyosalpinx, for instance, might 
be opened. 

When the cyst is above the brim delivery may usually be effected by 
version or forceps. 

Other Tumors of the Soft Parts. Broad ligament, tubal, and other 
swellings, if of sufficient size to cause serious obstruction in labor, are 
best treated by Cesarean section. A hydatid cyst should also be treated 
in this way. 

Inguinal and Crural Herniae. These may be forced down during labor 
and cause a great increase in pain and excessive straining. It may be 
necessary to hold the hernia back during the pains, or sometimes to anaes- 
thetize the patient and deliver by version or forceps. 

Floating Kidney. A kidney may be displaced downward and be adher- 
ent at the brim, causing an obstruction and increasing the patient' s suffer- 
ing greatly. It may be necessary to anaesthetize and deliver by version 
or forceps. 

Tumors of the Liver. Large hydatid cysts and carcinomatous tumors 
may obstruct labor. Version or forceps may be necessary, or Cesarean 
section. 

3. ANOMALIES OF THE FCETUS. 
Malposition of the Head. 

OCCIPITO-POSTERIOR CASES. 

There are two varieties: that in which the long axis of the head lies 
in the right oblique diameter at the beginning of labor — right occipito- 
posterior — and that in which it lies in the left oblique diameter — left 
occipito-posterior. The former is the more common. 

Labor is generally longer in these cases, partly because the head does 
not flex well on entering the pelvis, and so does not become well accom- 
modated to it, and partly because of the long internal rotation. The 
pains in the first stage are often irregular and imperfectly marked. 

Diagnosis. On external examination of the abdomen at the begin- 
ning of labor, the back of the foetus is not felt through the mother's 
anterior abdominal wall. If the parts are lax or thin, the irregular 
projections of the limbs of the foetus may be felt. The head may be 
palpated above the brim. The foetal heart is heard well around in the 
fl-ank between the iliac crest and the ribs. On vaginal examination the 
rounded head is felt through the fornices. When the cervix is opened 
sufficiently to allow the entrance of the fingers, the sagittal suture is felt 
in the line of the oblique diameter, and the posterior fontanelle is in the 
posterior half of the pelvis. 



146 



PATHOLOQ Y OF LABOR. 



Mi.« sanibm. The normal mechanism in a typical case is as follows : 
Flexion. 

I oterna] rotation. 
Extension. 
Externa] rotation. 
Flexion goes on slowly, and, following this movement, the occipital 
end of the head reaches the sacral segment of the pelvic floor. As a 

result of this, according to the teaching of 
Berry Hart, internal rotation is brought about, 
the occiput being thrown or directed forward 
Until it lies in the middle line anteriorly. The 
rest of the delivery proceeds as in an occipito- 
anterior case. 

Abnormal Occipito-posterior Cases. 1. In some 
cases the head does not flex well on entering the 
brim, owing to a small size of the head. The 
sinciput reaches the sacral segment of the pelvic 
floor before the occiput on the opposite side, and 
as a result, according to Hart's law, it is rotated 
to the front of the pelvis, the occiput turning 
into the hollow of the sacrum. Clinically, we 
always speak of this mal rotation as a rotation 
of the occiput to the back; but in reality, ac- 
cording to Hart, the essential feature is the an- 
terior rotation of the sincipital end of the head. 
The head may now remain in this position, which is termed " Per- 
sistent Occipito-posterior " or the " Face to Pubes" case. 

But natural expulsion may take place, the face passing under the sym- 
physis and the occiput over the perineum. This is accomplished with 
difficulty, and requires very strong pains, lax maternal parts, and not too 




Diagram showing head un- 
moulded and moulded in a per- 
sistent occipito-posterior case. 

Black, unmoulded. 

Red, moulded. 



Fig. 296. 



Fig. 297. 





Right occipito-posterior position of head. The 
arrow shows the direction of the long internal 
rotation made by the occiput in delivery. 



Left occipito-posterior position of head. The 
arrow shows the direction of the long internal 
rotation made by the occiput in delivery. 



large a head. The perineum is generally badly torn. The head flexes 
well before it passes through the outlet. After the birth of the head 
external rotation (really an internal rotation of the shoulders) occurs, and 
the body is born. 

The head-moulding in these cases is as follows: The occipito-mental 
and occipitofrontal diameters are much shortened, the suboccipito-breg- 
matic being lengthened greatly. 



ANOMALIES OF THE FCETUS. 



447 



2. In some cases, owing to the disproportion between the occipital end 
of the head and that part of the brim in relation to it, flexion is pre- 
vented, and the head may enter the brim in an extended position, giving 
a brow or face presentation. 

3. In another set of cases the head may enter the brim poorly flexed, 
and on reaching the pelvic floor may rotate only partially, remaining 
fixed in its long diameter, being in the transverse of the pelvic cavity. 



Fig. 298. 




Faulty mechanism in a right occipito-posterior case. The occiput is shown rotating to the hack. 

(After Schultze.) 



Management of Labor. The case should be carefully watched and 
frequent examinations should be made to determine whether or not flexion 
is taking place to a sufficient extent. If the mechanism goes on satis- 
factorily, the management is the same as in an occipitoanterior case. 

When flexion takes place badly it should be promoted, the sinciput 
being pushed up during the pains. This is best accomplished if the 
patient be placed in the genupectoral posture. 

If this be not successful, some authorities recommend that the woman 
be anaesthetized, the hand passed into the cervix and the head markedly 
flexed by pressing up the sinciput. The anaesthetic should then be 
stopped and the head kept flexed until pains return, forcing it into the 
brim. Should extension again be established, the following methods 
may be adopted : The foetus may be turned and delivered as a breech 
case; or the head and trunk may be rotated by the hand until the occi- 
put is anterior, and then may be delivered with forceps ; or forceps 
may be at once applied while the occiput is posterior. Most physicians 
employ the latter method. 



4 ig r.lTHOLOQY OF LABOR. 

Application op Forceps in a High Occipito-postebiob Cam-:. 

The blades are applied in the ordinary manner — i. c, right and left qua 
the pelvis. Aj the head is drawn into the cavity rotation tends to occur. 
Aa b result of this the blades are bo altered as to be ill-adapted to the 
pelvic curve, and they should, therefore, be removed as soon as the head 
is well through the brim. The case may then be left to nature, or the 
forceps may be reapplied. 

Recently Milne Murray has introduced axis-traction forceps for these 
cases to allow of continuous extraction of the head in spite of the rotation 
which occurs. The main feature which allows of this is the lessening 
of the curve of the blades. 

Application of Forceps when the Head is Low in the Pel- 
vis. When the occiput has not rotated to the front or has only partly 
rotated, the forceps will grasp the head obliquely or antero-posteriorlv. 
As traction proceeds the head tends to rotate. If this is marked, the 
blades should be removed and reapplied. Between tractions the handles 
should be separated, because sometimes the occiput tends to turn to the 
front spontaneously. 

When the occiput is in the hollow of the sacrum the sinciput should 
be kept well pushed up, in order to promote flexion and to allow head- 
moulding to occur. Then forceps should be applied and delivery brought 
about, the patient being placed in Walcher's position the better to pro- 
tect the perineum. As the head emerges it should flex, the root of the 
nose pivoting under the pubic arch. 

If necessary, the perineum should be incised on each side of the middle 
line to prevent a central rupture. 

Face Presentations. 

Frequency. Face presentations are not common. Various statistics 
are given, from 1 in 200 to 1 in 497. 

• Positions. The chin is the denominator and the positions are in order 
of frequency: 

R. M. P. 

L. M. A. 

L. M. P. 

R. M. A. 
Etiology. It is best to regard face presentations as altered vertex 
presentations. They very rarely exist before labor sets in, and, as a 
rule, they develop only as labor proceeds. The causes are varied; they 
may be tabulated as follows: 

1. Enlarged neck or thorax — e. g., due to tumor. 

2. Coiling of cord around neck. 

3. Folding of arms under chin. 

4. Excessive mobility of foetus. 

5. Small size of foetus. 

6. Excessive liquor amnii. 

7. Obliquity of uterus. 

8. Sudden escape of liquor amnii. 

9. Flat pelvis. 

10. Certain conditions of occipi to-posterior cases, in which there is a 
tight fit at the brim. 



ANOMALIES OF THE FCETUS. 



449 



By some dolichocephalic head is given, but it is doubtful if this shape 
ever exists in utero sufficiently marked to bring about a malpresentation. 
It is found after delivery in face cases, but the shape is due to the head- 
moulding. 

The factor in changing a vertex to a face presentation is evidently 
extension, and the student may easily understand how the above causes 
may induce this change. 

Diagnosis. The examination of the mother's abdomen reveals, in 
many cases, nothing different from what is found in a vertex presenta- 
tion. If the abdominal wall be lax, however, it may be possible to feel 
the furrow between the back and the occiput, owing to the extension of 
the head. There is also a lack of application of the body of the foetus 
to the uterus and abdomen. The bulging of the occiput at the side may 
be felt. On vaginal examination early in labor the rounded head felt in 
vertex cases is wanting. The fornix is high up and somewhat irregularly 
flattened across. 



Fig. 299. 




Mechanism of labor in a face case. Right mento-anterior. (After Schdltze.) 



When the cervix is somewhat dilated, forehead, nose, malar processes, 
and mouth may be distinguished. If much of a caput succedaneum has 
formed over the face, it may be mistaken for a breech; the mouth being 
mistaken for the anus, the nose for the coccyx, the malar processes for 
the ischial tuberosities, and the cheeks for the nates. Care must be 
taken not to injure an eye in making the examination. 

Prognosis. Labor is slow. The first stage is delayed because the 
head does not fit so well in the lower uterine segment as in a vertex case, 
and does not allow of the formation of so good a bag of waters. Ante- 
rior cases — i. e., those in which the chin is in front, are better than pos- 
terior, and the labor is quicker. 

29 



};,i) PATHOLOGY OF LABOR. 

In posterior oases malrotation may occur, usually requiring interfer- 
ence; the Bkull is compressed against the pubes. The maternal risk is 
not greatly over the normal; the risk to the child, compared with vertex 
oases, is computed to be as L3 is to 5. There is more danger of lacera- 
tion of the perineum. 

Mechanism. Normal, (a) In the most common anterior case — 
L. M. A. (this is simply an R. O. P. ease in which extension of the 
head has occurred). At firsl extension of the head goes on slowly, and 
it passes through the brim with its vertical diameter in relation with the 
inlet. As the foetus is pushed down it is evident that that part of the 
head which first reaches the sacral segment of the floor is the chin. It 
reaches the anterior part of the left half of the segment, and, in accord- 
ance with Hart's law, is rotated forward to the middle line under the 
symphysis. When internal rotation is complete, flexion follows. The 
mouth, nose, eyes, and forehead appear successively. Then the vertex 
conies over the perineum while the chin slides forward under the sym- 
physis. Finally the occiput sweeps over the perineum. Afterward 
external rotation or restitution occurs — in reality a rotation of the shoul- 
ders — and the body is next delivered. 

(6) In the most common posterior case — K. M. P. (this is an L. O. A. 
in which extension has occurred), at first extension of the head occurs. 
Long internal rotation then takes place, whereby the chin is brought to 
the front under the symphysis. The rest of the labor is the same as in 
the case of L. M. A. 

Abnormal, (a) In a large pelvis, sometimes, or in cases where the 
foetus is small, the head may be pushed through the pelvis without any 
special mechanism. 

Its long diameter may be fouud in relation with any diameter of the 
pelvis. In the flat rachitic pelvis it usually passes with its long diam- 
eter in the transverse. These abnormal de- 
Fi G . 300. liveries are most favored by death of the 

foetus, when its tissues become more lax. 

(6) Sometimes, in mento-posterior cases, 
abnormal internal rotation occurs, so that the 
chin, instead of being carried to the front, is 
turned to the hollow of the sacrum. Accord- 
ing to Hart, the explanation of this condition 
is as follows : It only occurs when the pelvis 
is very large or the head small. Extension 
of the head is imperfect, and the chin does 
not strike the sacral segment on its own side. 
Diagram showing head un- It is the sinciput which strikes the opposite 
moulded and moulded by labor in segment, and is, therefore, rotated to the front. 

a case of face presentation. t i 1 1 i • 1 i • 1 i ■ • 

Black, unmouided. ln other words > that which we describe chni- 

Red, moulded. cally as a rotation of the chin to the back is 

really a forward movement of the sinciput. 
This condition is a bad one. It is very rare that natural delivery fol- 
lows, and then only when the head is very much smaller than the pelvic 
cavity. It is apt to become arrested, being then known asa" persist- 
ent inento-posterior " case. The reason of this is evident. The chin 
is jammed in the curve of the sacrum, and if the head is to be born 




ANOMALIES OF THE FCETUS. 451 

the coccyx must be excessively bent back, the sacro-sciatic ligaments 
and perineum greatly stretched, and the cranial vault greatly flattened. 

Head-moulding. After an ordinary face delivery the vault of the 
head is seen to be flattened, the supra-occipital being pushed backward 
and the convexity of the frontals increased. The transverse, occipito- 
frontal, and occipito-mental diameters are increased, the suboccipito- 
bregmatic lessened. 

The caput succedaneum is found on the face : in mento-posterior 
cases in the upper malar region and region of the eye (thus, in the 
K. M. P. case, on the right side of the face); in mento-anterior cases in 
the lower malar region, about the angle of the mouth (thus in L. M. A., 
on the left side of the face). In other words, the caput is formed over 
that part which has been especially placed in relation to the deficiency in 
the anterior pelvic wall below the pubes. The skin may be greatly dis- 
colored. The eye may be closed for some days, or the mouth may be 
incapable of suckling for a short time. 

Management. The bag of membranes should be preserved as long 
as possible, because the face is so poor a dilator. Sometimes the case 
may be left to nature — i. e., when the woman is a multipara who has 
had easy labors, when the pelvis is roomy and the soft parts easily dila- 
table, when the pains are good, and when the chin is anterior. 

Internal rotation may be favored by the turning of the chin forward 
with the fingers during the pains. 

In posterior positions of the chin, or in anterior positions when any 
abnormal condition exists, interference is necessary. 

Different procedures are recommended. At first the patient should be 
anaesthetized and an effort made to bring about a vertex presentation by 
external manipulation through the anterior abdominal wall. But if this 
procedure fail, the following means may be tried. 

When the chin is posterior an attempt may be made, first of all, to 
restore a vertex presentation by pushing up the sinciput. When the 
chin is anterior this would only result in an occipito-posterior position, 
and, therefore, it is not to be recommended. If restoration is carried 
out and the vertex engages,, the case may be left to nature; if engage- 
ment does not soon take place, forceps should be applied. 

If restoration of the vertex presentation be not possible or advisable, 
delivery by version may be employed. If version be impossible or 
dangerous, owing to the conditions present, forceps may be used in an- 
terior positions. This is a difficult and dangerous mode of treatment, 
and is only to be undertaken as a last resort. The grip of the blades 
is bad for the child, and also for the mother, on account of the width 
between them. When the chin is posterior they should not be used at 
all, because if the head passes the brim, it tends to move, so that the chin 
goes into the hollow of the sacrum. 

When delivery is impossible by these procedures, embryulcia is justi- 
fiable. 

When the head has passed the brim and tends to be delayed, in spite 
of the efforts to promote extension and internal rotation, there is always 
danger to the child from the tension on the vessels of the neck and from 
the pressure against them, endangering the cerebral circulation. In such 
a case forceps should be employed. They must be used carefully, as 



152 PATHOLOQ P OF LABOR, 

there is L r r»':it risk that the blades may press dangerously <>n tlie nerves 

and vessels of tin- neck. 

When the chin has rotated into the hollow of the sacrum, efforts should 
be made to rotate it to the front, the patient being amesthctized, if 

necessary. If this is impossible, the usual plan is to attempt delivery 
with forceps. When the head is passing the perineum the latter should 
he incised on each side to lessen the risk of had laceration, and the 
patient should be in Watcher' s position. As soon as the chin is horn 
the rest of the head should be brought out by flexion. If this method 
of delivery be impossible, or if the child be dead, embryulcia may be 
performed. Recently, however, owing to the success of symphyseotomy, 
it is strongly recommended that in a persistent occipito-posterior case 
this operation should be performed before delivery is attempted with 
forceps. 1 "here is far greater chance of getting a living chili, and the 
risk to the mother is not much increased. 

Brow Presentations. 

Frequency. Brow presentations are very much less frequent than 
face cases. They are only a half-way stage in the development of the 
latter, the head being only partially extended. The most frequent posi- 
tion is that in which a vertex L. O. A. has been changed; the next most 
frequent that in which a vertex R. O. P. has been altered. 

Etiology. The causes are the same as in the case of face presenta- 
tions. 

Diagnosis. By external examination the condition cannot be made 
out. When labor has begun and the fingers can be passed within the 
cervix, the root of the nose, the margins of the orbits, and, possibly, the 
anterior fontanelle, may be felt. 

Mechanism of Labor. 1. In certain cases where the child's head 
is rather small a special mechanism may take place. The head passes 
through the brim in the extended position, the occipito-mental diameter 
having been diminished in length. The brow descending to the pelvic 
floor is then rotated to the front until it lies opposite the vulva, the face 
being behind the pubes and the chin at its upper margin; the occiput 
lies in the hollow of the sacrum. Flexion then occurs, the cranial vault 
sweeping over the perineum; the nose, mouth, and chin afterward pass- 
ing under the symphysis. The body is then born, rotation taking place 
for the delivery of the shoulders. 

2. Sometimes, when the pelvis is very large or the child small, the 
latter may be pushed through the pelvis without any mechanism. 

3. A natural change in the presentation may take place to a vertex or 
to a face. 

Head-moulding. After the mechanism described above, the head 
is characteristically altered. The caput succedaneum reaches from the 
root of the nose to the anterior fontanelle, the forehead is somewhat per- 
pendicular, and the parietal and occipital bones slope downward and 
backward. On profile the head has thus a somewhat triangular shape. 

In a case which has begun as a brow and finished as a face, the head 
is dolichocephalic, with a marked caput succedaneum on the forehead and 
one on the face. 




ANOMALIES OF THE FCETUS. 453 

Management. On diagnosing a brow case early in labor the sinci- 
put should always be pushed up, in order to bring about an engagement 
of the vertex, pressure being made during the pains. The case may 
then be left to nature, or forceps may be used. If the vertex presenta- 
tion cannot be produced successfully, and if the case be one in which 
the brow position is posterior (i. e., in which 
originally the occiput was to the front), delivery FlG - 30L 

by version should be proceeded with. It is not 
wise to change the presentation to that of a face 
in this condition, because the chin will be made 
to lie posterior. If, however, the case be one 
in which the position is anterior, instead of per- 
forming version some prefer to bring about ex- 
tension to the head, and so to get a face presen- 
tation, the chin being to the front. The case 
may then be left to nature, or may be treated in 
the various methods recommended for face pre- 
sentations. Diagram showing head un- 

When these procedures canuot be carried out, moulded and moulded by labor 
and labor is delayed, it may be necessary to at- m a case of brow presentation. 
tempt delivery with forceps, a procedure which Re^mouMe^^ 

is unfavorable both for child and mother. 

When this is impossible or too dangerous, embrylucia may be per- 
formed. 

Now, however, it is highly probable that symphyseotomy will displace 
both the use of forceps and embryulcia in these cases. 

When labor is delayed after the head has entered the pelvis, forceps 
is indicated. When mal rotation has occurred and the chin is posterior, 
the use of forceps is difficult and dangerous, and the case must be treated 
practically as one of persistent mento-posterior face. 

Pelvic Presentations. 

Frequency. According to the statistics of Pinard, pelvic presenta- 
tions occur in the proportion of one in thirty labors; excluding miscar- 
riages and premature births, however, he finds it to be about one in sixty. 
In the majority of cases the breech presents; in the rest either the knees 
or the feet present. 

The positions in order of frequency are : 
L. S. A. 
R. S. P. 
R. S. A. 
L. S. P. 
The denominator is the sacrum. 1 

Etiology. The conditions favoring a pelvic presentation are exces- 
sive liquor amnii, lax uterine and abdominal walls, obliquity of the 
uterus, multiparity, multiple pregnancy, monstrosity, death or prema- 

1 Berry Hart objects, rightly, to the use of the sacrum as the denominator. We do not follow the 
sacrum in the mechanism of labor, but the hip which is nearest the front. Therefore, to keep up 
uniformity of description in the various mechanisms, he desires to denominate the positions in refer- 
ence to the hip. 



\r>\ 



PATHOLOGY <>F LABOR. 



turity «>f foetus, placenta praBvia, contracted pelvis, tumors of uterus or 
neighboring structures. 

Diagnosis. On abdominal examination, the head is felt in the upper 

part of tlir litems. The foetal heart-SOUnds arc heard above the level 

of the umbilicus. 

( )n vagina] examination, early in labor, the hardness of the head is 
missed through the fornices. After labor has advanced the examining 
fingers may recognize through the cervix, the sacrum, coccyx, and ischial 
tuberosities. The anus is felt as a dimple below the skin level. If the 
child is dead, however, it may be gaping and may project as an eminence. 



Fig. 302. 



Fig. 303. 





Breech presentation. Right sacro-posterior. 
Feet and cord in relation to os internum. (After 
A. R. Simpson.) 



Pelvic presentation. Left sacro-anterior 
position. (After A. R. Simpson.) 



If the child be a male the penis and scrotum may be felt; the latter 
should not be mistaken for the bag of membranes. The finger should 
be passed into the groin, which is distinguished from the axilla by the 
absence of ribs. Movements of the feet are felt when the case is a foot- 
ling presentation. The foot must be distinguished from the hand by the 
presence of the projecting heel and by the parallel toes. 

The feet usually lie close together. The knee is distinguished from 
the elbow by the presence of the patella, by its larger size, and by the 
absence of the sharp olecranon. 

Meconium may be distinguished in the vaginal discharge. It is abun- 
dant and tarry, not in flakes. 



ANOMALIES OF THE FOETUS. 



455 



A breech may be mistaken for a face (see page 449). 

Prognosis. In cases which are uncomplicated the maternal risks are 
no greater than in vertex cases. The risks are those of interference. 
They are laceration of the cervix and perineum, inertia of the uterus 
from too rapid delivery or from loss of blood, separation of placenta 
from too rapid delivery. 

The risks to the child are great, the mortality being about 1 in 10. 
These are due to prolapse of the cord and pressure on it; early escape 
of the liquor amnii, which is apt to occur, because the girdle of contact 
does not grasp the breech as well as it does the head, and, the forewaters 
not being completely shut off from the rest of the liquor amnii, the mem- 
branes burst under an abnormal degree of the force of uterine contrac- 
tion; partial or complete separation of the placenta from hurried delivery 
or prolonged compression of the placenta, leading to gradual asphyxia or 
to sudden death. Fractures and dislocations may be caused by interfer- 
ence. It is stated by Koettnitz that hematoma of the sterno-mastoid 
and torticollis are most frequent in connection with breech delivery. 

Mechanism. The normal mechanism usually takes place as follows : 
The breech is either pushed straight down through the pelvis, or the 



Fig. 304. 




Passage of buttocks over perineum m a breech case. (After Barnes.) 

anterior hip may descend somewhat in front of the other. This hip on 
reaching the sacral segment of the pelvic floor is rotated to the middle 
line in front, this movement being known as internal rotation. It 
becomes fixed at the pubic arch, while the trunk is more driven down 
into the pelvis and the posterior hip moves forward to the perineum, 
which gradually retracts over it. The anterior hip is then somewhat 
released from being pressed against the pubic arch, and the whole pelvis 
moves onward, followed by the rest of the trunk, with the lower and 
upper extremities, both being in an attitude of flexion. Sometimes 
the lower limbs are not bent at the knees, but lie straight on the front 
of the body. This is less favorable, and may cause delay iu labor, 
because the straight limbs act as splints, as Tarnier has stated, interfering 
with the flexing of the trunk and with its accommodation to the pelvic 
'curve. The shoulders pass the brim, their long diameter in the trans- 
verse. The head passes flexed, its antero-posterior diameter lying in the 



456 PATHOLOGY OF LABOR 

oblique or transverse of the brim. When it is well in the cavity rotation 
occurs, bo that the oociput turns to the front, the face being in the sacral 
hollow. The face and the forehead arc then born, followed by the res! 

of the head. 

Moulding of the Fostus. The breech Is swollen. It may be only 
oedematous, or may present a large, dark swelling. This is generally 
over the anterior hi]), but it may spread to the region of the genitals, and 
may especially affect the scrotum in the male. These signs may also be 
found in the knees or feet when they present. 

ABNORMALITIES in the Mechanism. 1. The breech may stick at 
the brim and may not engage. This is especially apt to be the case 
where the pelvis is contracted. 

2. Having entered the brim the body may stick, no further advance 
being made. This condition of matters may be due to the small size of 
the pelvis, abnormal size of the foetus, contraction of the cervix, or to 
the extended position of the limbs on the anterior surface of the foetus. 

3. The arms may be displaced upward, one or both being in front, 
behind, or at the sides of the head. This may be due to contraction 
of the cervix on the body above the pelvis of the foetus as it descends, 
or to the small size of the pelvis; but it is important to note that it 
may follow too hurried emptying of the uterus when there is artificial 
delivery. Very often, when the lower limbs are displaced, the upper 
limbs are apt also to be displaced. 

This condition causes a delay in labor, which usually requires special 
treatment. The life of the child is endangered from the extra risk of 
pressure on the cord. 

4. The head may become impacted above the brim or in the pelvic 
cavity. This usually happens as a result of extension from too rapid 
delivery of the child. In other cases, where the pelvis is relatively 
large, and the sacrum directed toward the back, the anterior hip may 
not turn to the front, but the body of the foetus passes straight through 
the pelvis, the shoulders passing the brim in relation with the transverse 
diameter. The head may descend and normal rotation of the occiput 
take place. But rotation may not occur, the occiput remaining in the 
hollow of the sacrum. 

In some of the cases in which the head gets extended at the brim the 
chin is apt to catch above the pubes and to delay labor. 

In cases, also, where the back of the foetus is to the front the head 
may stick above the brim if extension occurs. 

In the pelvis the head may also stick in the transverse from incom- 
plete rotation, or in the antero-posterior diameter, the occiput being to 
the front, owing to extension of the head having caused the chin to get 
fixed in the sacral hollow. 

General Management. No attempt should be made to alter the 
presentation, nor to interfere as long as labor progresses naturally. The 
physician should watch the case more closely than in a normal vertex 
case, and should have skilled assistance within easy reach. Dilatation of 
the cervix may be promoted by means of hot douches. But if the mem- 
branes have been driven down as a sausage-like pouch, or have ruptured 
early, Champetier de Ribes's or Barnes's bag may be used, and nature 
may be allowed to expel the pelvis and lower extremities. When the 



ANOMALIES OF THE FCETUS. 457 

umbilicus appears, a piece of cord is pulled down and examined. If it 
is pulsating well, nature may be allowed to continue the delivery. The 
exposed parts may be protected with a warm cloth and held up from the 
perineum. 

When the hands appear they may be freed. If it is found that pulsa- 
tion in the cord be feeble or has just ceased, it is necessary to hasten 
delivery. 

Fig. 305. 



Delivery of child In a breech case by pressure on fundus uteri and by traction on lower limbs. 

(After A. R. Simpson.) 

Another indication in the same direction is spasms of the body due to 
respiratory efforts. Speedy delivery is attained by suprapubic pressure 
on the uterus, accompanied with traction from below. Of very great im- 
portance is the former of these. The traction should be made in the 
axis of the pelvis, at first well backward against the perineum. 

Sometimes the cord passes between the legs of the child. In such a 
case a loop should be pulled down and slipped up over the posterior 
thigh. If this be impossible, or if the cord is wound around the body, 
it should be doubly ligatured and divided. Then delivery should be 
hastened. 

Management in Special Conditions. Non-engagement at the Brim. 
When the breech does not engage in the brim, a lower limb should be 
brought down, provided there be no undue contraction of the brim. The 
case may then be continued by nature; but if the patient be exhausted, 
slow artificial delivery should be carried on by means of pressure from 
above the pubes and by traction from below. The latter manoeuvre should 
be carried out as follows : The foot should be grasped between the first 
and second fingers. The other foot need not be brought down unless it 
is bent over the child's back or crosses the other leg. The limb should 
be drawn down slowly and by stages. When the leg is beyond the vulva 



458 



PATHOLOGY OF LABOR. 



it should In 1 covered in a warm cloth and held by the whole hand. In 
pulling do marked friction against the pubio arch should occur. As die 

child descends it should be grasped close to the mother's vulva. When 
the breech reaches the perineum the traction should be more in the axis 
of the outlet. A- the lower part of the abdomen appears the other leg 
usually falls out. The rest of the delivery should imitate the natural 
process. 

Fig. 306. 




Delivery of child in a breech case by traction made with fingers placed in groin. 
(After A. R. Simpson.) 

Impaction of the Breech. When, having entered the pelvis, the breech 
sticks, various procedures may be adopted. Here it is impossible to pull 
down a limb safely. The index-fingers hooked into the groin may be 
sufficient to promote descent by traction. Better, however, is a fillet, 
such as a soft piece of silk cloth. An aseptic gum-elastic catheter 
threaded with a loop of string may be used to pass the fillet around the 
groin. A blunt hook is also sometimes used for the purpose of extrac- 
tion, but is apt to cause injury. The line of traction should be toward 
the side on which the sacrum lies, in order that fracture of the thigh may 
be avoided. 

Forceps may also be applied to the breech in such a case, though Dot 
without some difficulty. 

Sometimes delivery by these means is impossible, and embryulcia is 
necessary, a grip being obtained with a cranioclast, or crushing of the 
pelvis being performed with a cephalotribe. The after-coming head 
should also be perforated in such a case to render its passage more easy 
and to insure death of the child. 



ANOMALIES OF THE FCETUS. 



459 



Upward Displacement of the Arms, (a) When the head is still above 
the brim. When the brim does not allow the passage of the head and 
arms, jamming occurs just about the period when the tips of the scapulae 
appear at the vulva. It is then necessary to free the arms. The body 
of the foetus should be pushed a little upward in order to diminish the 
pressure on the arms at the brim, and the child's body should be rotated 
until its back is directed toward one or other side of the mother. It 
should then be pressed well forward against the symphysis, in order that 
an attempt may be made to free the arm which is most posterior. The 
hand is passed upward into the hollow of the sacrum and the first two 
fingers along the side of the neck behind the posterior arm as far as the 

Fig. 307. 




Method of freeing the anterior arm displaced upward in a breech delivery. 
(After A. R. Simpson.) 



elbow. The latter should then be swept over the face and thorax until 
it comes to lie within the pelvic cavity. The body of the child is then 
pressed backward against the perineum, and an attempt made to bring 
down the anterior arm by a proceeding similar to that employed in the 
case of the other one. Sometimes it is impossible to get room enough 
to carry out this latter procedure. In such a case the body of the child 
should be carefully rotated by both hands placed on the thorax, the back 
of the child moving across the front of the mother's pelvis. The thorax 
should be well pushed up when this manoeuvre is begun, in order to 
diminish the risk of dislocating the neck. By this rotation of the back 



460 



PATHOLOGY OF LABOR. 



of the child from one side of the mother's pelvis to the other, the arm 
which was anterior is made to lie posteriori and then it may be more 

easily drawn down. 

(6) When the head is below the brim. The release of the arms in 

this position is much easier than when placed above the brim. The pro- 
cedure is practically the same. The trunk should Bret be drawn down 
as far as possible. Usually the posterior arm is first brought down; but 

the best rule is to release that one which is most accessible, the child's 
trunk being directed well toward the mother's pubes or perineum, as the 

may be. 

Fig. 308. 




Method of freeing the posterior arm displaced upward in a breech delivery. 
(After A. R. Simpson.) 



In some cases an arm gets jammed over the back of the head between 
the occiput and the pelvic wall. In freeing it the fingers should be 
passed up over the back of the foetus, and the arm carefully pushed 
around the side of the head to its own side. The elbow may then be 
drawn down over the face and thorax. Sometimes the arm in such a 
case may be released from its dorsal position by rotating the body in the 
opposite direction from that which caused the trouble. 

In all these manipulations on the arms there is danger of dislocating 
the shoulder-joint, of separating the epiphysis at the upper end of the 
humerus, of fracturing the humerus, clavicle, or spine of the scapula, 
or of injuring nerves. The traction should, therefore, be made in the 
bend of the elbow. 

In cases where this method fails, division of the clavicle may be per- 
formed — cleidotomy — to diminish the size of the shoulder-girdle. 

Constriction of the Head by the Uterus. Sometimes the retraction ring 
of the uterus may grasp the head tightly; sometimes the cervix may be 
closely retracted on the neck. This condition greatly endangers the life 



ANOMALIES OF THE FCETUS. 



461 



Fig. 309. 



of the child, and delivery must be rapid. The patient should be deeply 
anaesthetized, and traction made on the shoulders and mouth, or forceps 
should be applied. 

Impaction of the Head. This may take place at the brim or in the 
pelvis. It may be due to the large size of the head or small size of the 
pelvis, or to some other form of obstruction. It may also be caused by 
the extension of the head when there is a want of suprapubic pressure. 
Generally, however, it is due to extension of the head, brought about by 
traction on the foetus unaccompanied with suprapubic pressure. 

The methods of delivery employed in these cases are : 

1. Manual Extraction, (a) By the Smellie Grasp. The body of 
the child is covered in a warm cloth and is placed on the flexor aspect 
of the physician's forearm, the legs hanging 
down, one on each side. The fingers of this 
hand are passed into the vagina, the first and 
second fingers being placed in the fossse on 
each side of the child's nose. The fingers of 
the other hand are then passed up over the 
back as far as the occiput. By pulling down 
with the fingers that are on the face, and 
pushing up with those of the other hand, the 
head is flexed. Then, by raising the trunk, 
the head is born and the face is delivered 
over the perineum. 

(6) By the Prague Grasp. Some physicians 
prefer this grasp. One hand grasps the feet, 
by which the body can be drawn well back 
over the mother's perineum. The fingers of 
the other hand are hooked over the shoulders, 
and then traction is made downward by both 
hands, the body being gradually carried to- 
ward the pubes as the face is drawn over the 
perineum. 

(c) Smellie -Veit or Mauriceau Method. 
This is the combined method of traction on 
the lower jaw and shoulders. The first two 
fingers of the hand that is in relation to the 
anterior aspect of the child are placed in the 
mouth, while the fingers of the other hand 
grasp the shoulders. The child is first drawn 
downward, and then the body is carried to- 
ward the pubes, while the face sweeps over 
the perineum. 

Care must be taken not to fracture or dislocate the lower jaw. 

(d) Wigand-Martin Method. One hand is used with the fingers over 
the shoulders astride the neck to extract the child, while the other presses 
the head down from above the pubes. 

2. Forceps Extraction. When the foregoing methods fail, forceps 
may be used. They are chiefly serviceable when the perineum is very 
rigid and when the head is arrested at the brim. In applying the blades 
the body of the foetus should be carried well against the pubes. When 




Prague grasp. 



462 



PA THOLOOY OF LABOR. 



the occipul is to the back they will lie under the hack <>f the child; when 
it is to the t'n>nt they will lie under the abdomen. 



Pig. 810. 




The Smellie-Veit method of extracting the after-coming head. (Doderlein.) 



Fig. 311. 




The Wigand-Martin method of delivering the after-coming head. (Doderlein.) 



3. Delivery after Embryulcia. In cases in which the head 
cannot be delivered by any of the above methods, reduction of the head 
by perforation is necessary. This may be done through the skull or 
through the base of the mouth. 



ANOMALIES OF THE FCETUS. 



463 



Malrotation of the Head. Sometimes in the pelvis the head 
stays with its long diameter in the transverse, or with the occiput in the 
hollow of the sacrum. In these cases it is best to hold the head and 
trunk firmly by the Smellie grasp and to rotate them so that the occiput 
comes to the front, delivery being continued as already described. 

Transverse Presentations. 



Frequency. Various statistics are given, varying from 1 in 150 to 
1 in 300. It might be generally stated that less than J per cent, of all 
cases of labor present transverse presentations. 

Causes. The causes are those of malpresentation in general — -e. g. y 
excess of liquor amnii; prematurity of labor; death of the foetus, by 
which its tone is lost; changes in the shape of the foetus by disease — e. g., 
hydrocephalus; malformations and monstrosities; multiple pregnancy; 
irregular contractions of the uterus; tumors of the uterus; tumors of 
parts near the uterus; uterine malformations; placenta prsevia. 

Fig. 312. 




Transverse presentation. Dorso-posterior, head on right side, arm prolapsed. (Faeabetjf.) 

Varieties. Any part of the body of the foetus may present; usually 
it is the shoulder, sometimes the hand or elbow, rarely the trunk. The 
long axis of the trunk is very rarely transverse; it is usually obliquely 
placed in relation to the long axis of the uterus. 



464 



PATllolJXiY OF LABOR. 



Positions. Attention need be paid only to the shoulder cases. The 
nomenclature employed differs m different countries. By some the acro- 
mion process is nx>i\ as the denominator, by others the spine of the 

scapula. ( ertain writers prefer to make use of no denominator what- 
ever. It is, indeed, quite sufficient to classify die positions as follows: 
Dorso-anterior : 

1 lead on the right side. 
Head on the left. 
Dorso-posterior : 

1 lead on the right side. 
Head on the left. 
The dorso-anterior position, the head being on the left side of the 
mother, is the most frequent, and to it we will particularly allude in 
describing the mechanism of labor. 

Diagnosis. External abdominal examination reveals the unusual 
shape of the abdomen. The normal regular prominence of vertex and 



Fig. 313. 




Transverse presentation. Dorso-anterior, head on left side, arm prolapsed. (Farabeuf.) 



breech cases is absent. The regular pyriform shape of the uterus is 
wanting. It is felt to be moulded somewhat obliquely or transversely 
by the foetus. The head lies usually in an iliac fossa. The back is made 
out if it be to the front, or the irregularities of the limbs if they are 



ANOMALIES OF THE FCETUS. 465 

anterior. The foetal heart-sounds are heard below the umbilicus in a 
dorso-anterior position, being conducted along the back of the foetus. 

If labor has been delayed and the uterus has been active, there may 
be an abnormal thinning and stretching of the lower uterine segment, so 
that the foetal parts may be felt very distinctly just above the symphysis; 
and, higher up, the thickness of the retraction ring, where the lower 
uterine segment of the body of the uterus joins the upper, may be made 
out. 

On vaginal examination early in labor the presenting part is usually 
very high, the vaginal fornix being somewhat flattened. The lower 
uterine segment is imperfectly filled, and the cervix may be felt hanging 
loosely. As labor proceeds the bag of membranes tends to protrude into 
the vagina in a sausage form and to be ineffective as a dilator. It tends to 
rupture early, and the cord also tends to prolapse. When the fingers can 
be passed into the cervix the shoulder may be recognized by the three 
bony ridges, clavicle, humerus, and spine of scapula running toward a 
central spot. A finger may be passed into the axilla, and the ribs felt, 
thus distinguishing it from the groin. 

Sometimes the elbows or hand may be distinguished. The diagnosis 
of these from knee and foot is given on page 454. To know which hand 
is prolapsed, it is best to shake hands with it, and thus to identify it. 

Prognosis. In cases left to nature the risk both to mother and child 
is very great. The risk may be increased by the causes of the malpre- 
sentation. As artificial delivery is now the rule in these cases, the prog- 
nosis is modified by and dependent upon the nature of the operative 
interference. The longer labor is allowed to proceed before treatment is 
carried out, the greater is the danger to the mother. 

The chief risks to the mother are exhaustion, rupture of the uterus, 
the results of operative interference, and after-inflammation. We have 
already referred to the great thinning and stretching of the lower uterine 
segment in a delayed transverse case; it is this part which is most apt to 
be ruptured. 

Methods of Spontaneous Delivery. 1. Spontaneous Version. 
This is the change by which nature alters the presentation from the 
transverse to that of the head or breech, the delivery then taking place 
according to the new presentation. This is most apt to occur in multi- 
parse whose uterine walls are lax. It is more apt to occur in the case of 
a living than of a dead child. 

This version may occur before the membranes have ruptured as well 
as afterward. In the former case the pains may be weak. In the case of 
version after the membranes have ruptured, the amniotic fluid having 
partly or wholly escaped, the presenting part must be movable and not 
jammed in the cervix or brim, and the uterine pains must be strong. 
As the uterus contracts on the foetus it is driven against the cervix, which 
is only partly dilated, firm, and resistant. The presenting part is grad- 
ually displaced to one side, and this is continued until version is partly 
or wholly completed. 

(It is interesting to note that occasionally, if left to nature, a complete 
rotation may be carried out, one transverse presentation being substituted 
for another. This only takes place when there is a small child and 
plenty of liquor amnii.) 

30 



466 



PATHOLOGY OF LABOR. 



'2. Spontaneous Evolution, (a) Most common variety (Douglas). The 
delivery in this variety is by a special mechanism. Certain conditions 
are favorable to its successful progress. The pain- must be Btrong, the 
pelvis roomy, and the foetus small. Softness and compressibility of the 
foetus are particularly likely to favor this mechanism. There is no doubt, 
however, that it may take place where the foetus and pelvis are of normal 
size. Very Strong pains are the chief essential. 

First of all, the foetus is packed into the brim, the presenting shoulder 

being forced downward to the pelvic floor, and rotated forward until 
it rests under the pubic arch, where it sticks, the corresponding arm 
usually hanging outside the vulva. At this period the foetus is bo Lateri- 
flexed that the head is above the brim, lying alongside the breech, the 
latter being posterior. The chest is now driven down past the shoulder, 



Fig. 314. 




Spontaneous evolution. First stage. 



Spontaneous evolution. Second stage. 



then the abdomen and lower limbs, the presenting shoulder all this time 
pivoting on the pubic arch. Finally the head enters the pelvis and 
rotates, so that the occiput passes under the symphysis as its delivery is 
completed. 

(6) Rare variety (Roderer, Kleinwachter). In this form the body is 
delivered with doubled body (evolutio conduplicato corpore). The condi- 
tions which favor it are compressibility of the foetus, small size of the 
foetus, and a large pelvis. When the foetus is dead, therefore, it can the 
more easily occur. 

The presenting shoulder is pushed down into the pelvis, the head also 
being crowded into it along with the body. The arm belonging to the 
lowermost shoulder protrudes from the vulva; the other one lies between 
the breech and the head. The mass thus doubled is driven down, the 
presenting shoulder being delivered first, then head and chest together, 
and, finally, the breech and legs. 



ANOMALIES OF THE FCETUS. 



467 



Management. Transverse cases should not be left to nature. Arti- 
ficial delivery must be carried out. If the condition be diagnosed before 



Fig. 315. 




Spontaneous evolution. Third stage. 
Fig. 316. 




Spontaneous evolution. Fourth stage. 



the membranes are ruptured or the presenting part jammed at the brim, 
version should be performed. The bipolar or Braxton Hicks' s method 



468 



PATHOLOGY OF LABOR. 

riO. 317. 




Spontaneous evolution. Fifth stage. 



Fig. 318. 



should be adopted when the cervix 
is only partly dilated, the vertex or 
breech being made to present. If 
it is a shoulder case, it is best to try 
to bring about a vertex presentation 
unless the pelvis be flat, in which 
case a breech presentation is best. 

If the abdomen presents, a pelvic 
presentation should be induced. 

At first external manipulations 
through the abdominal wall should 
be tried, in order to turn the foetus, 
anaesthesia being employed. If this 
method fail, other measures must be 
carried out. 

When the cervix is well dilated 
the bipolar method may also be 
adopted if the liquor amnii is still 
in utero. When it has escaped, in- 
ternal or podalic version must alone 
be tried; before the rupture of the 
membranes this method may also be 
employed, the membranes being rup- 
tured artificially. 

How long after the escape of the 
liquor amnii it is feasible to perform 
podalic version, cannot be definitely 
stated. Different authorities give 
different limits. The student should 
bear in mind that the nearer to the 
time of rupture, the easier and safer 
Birth of child doubled. Evoiutio condupiicato is th proce( lure. It should never be 

corpore. (Kleinwachter.) ^ 




ANOMALIES OF THE FCETUS. 469 

carried out when the uterus is firmly contracted on the foetus, or when 
the latter is jammed into the inlet. There is always risk of rupturing 
the uterus. The patient should always be deeply anaesthetized in per- 
forming internal version. 

In transverse cases where turning is impracticable, the child must be 
broken up by one or other of the following methods : 

Decapitation may be carried out, when the neck is accessible, by a 
blunt, a serrated, or a sharp hook. The body may then be extracted, 
and afterward the head. 

Evisceration, or removal of the contents of the abdomen and thorax, is 
recommended by some. This is not, however, a satisfactory procedure. 

Spondylotomy, dividing the spinal column with scissors, or spondylo- 
lysis, breaking it up with a basilyst, is a better means of reducing the 
size of the child before extraction. 

Prolapse of the Limbs. 

(a) In Head Presentations. 1. One or both arms may be prolapsed in 
front, behind, or at the sides of the head. When one arm prolapses it 
usually lies close to the temporal region. The worst form is that in which 
the arm is across the back of the neck. Sometimes the arms are folded 
under the chin, bringing about a brow or face presentation (q. v.). 

Treatment. If the condition be diagnosed before rupture of the 
membranes, nothing should be done until the cervix is completely dilated. 
Then the hand may be pushed up to allow the head alone to engage in 
the brim. If this fail, forceps may be applied to the head if there be no 
risk of catching the arm, or version may be carried out. In extracting 
with forceps the arm may slip up. When the case is made out only 
after the arm is well engaged in the brim, the head should be delivered 
with forceps. 

2. A foot may present with the head. The line of treatment is the 
same. Embryulcia may sometimes be necessary. 

(b) In Breech Presentations. Sometimes the hand presents. Nothing 
need be done. The hand may or may not slip up. 

(c) In Transverse Presentations. If a foot presents, the condition is 
not unfavorable, for as version is the usual treatment, it can be carried 
out more easily. If an arm presents, it may interfere with the entrance 
of the physician's hand prior to the performance of podalic version. 
Sometimes it may be pushed up out of the way while the operator's hand 
is being introduced. Generally it is advisable to fasten a piece of tape 
around the prolapsed wrist, so that it may be drawn out of the way and 
prevented from ascending during the delivery of the thorax. 

Anomalies of Foetal Development. 

Shortness of the Cord. This may be "absolute" when the cord has 
only a length of a few inches, or "accidental" when the length is 
reduced by coiling around the neck, body, or limbs. The latter is more 
frequently a cause of delay in labor. Sometimes the placenta may be 
detached in this condition; sometimes the cord ruptures, or is so com- 
pressed as to lead to the death of the child. Most umbilical cords break 



470 PATH' >!.<><, ) OF LABOR 

under a weight of 8J pounds; Bome resist as much as L5 pounds; others 
will not Bustain (5 pounds. 

It is difficult t<> Btate what actually constitutes a short cord. It varies 
with the amount of Btretching it will hear, with the place of attachment 

to the placenta, with the Bite of the placenta, and with the tightm 
the coil-. 

'I'm: DIAGNOSIS of this condition is not easy. Sometimes there is 
marked pain at the placental site during contractions, marked recession 
of the head between pains, delayed labor, and occasionally irregular foetal 
heart-action. 

When the cord encircles the foetus and the latter is driven down, it 
rotates partly with the pains to undo the coiling, and so to relieve tension. 
Tin: TREATMENT consists in freeing the coils, where it is possible, or 
in dividing the cord and delivering by forceps. If the cord cannot be 
ligated, two artery forceps may be attached to it, and it may be divided 
between them. Where these procedures cannot be carried out forceps 
should be applied if the head presents, and labor should be hastened if 
it be a breech case. 

Unduly Ossified Skull. The skull bones may be prematurely or abnorm- 
ally ossified, the sutures and fontanelles being partly or wholly closed. 
The head fails to undergo moulding in labor and delay results; it may 
be arrested in the brim or pelvic cavity. 

The application of forceps, symphyseotomy, or embryulcia may be 
necessary to delivery. 

Large Size of the Foetus. In the case of a large child — e. g., eleven 
pounds or more, there may be delayed labor. There are records of chil- 
dren delivered weighing more than twenty pounds. The causes are not 
definitely known. It is thought that multiparity, large size or advanced 
age of one or both parents, and unusual extension of the period of preg- 
nancy are related to its occurrence. 

The mechanism of labor by which the head attempts to pass through 
the pelvis is like that which takes place in a justo- minor pelvis, viz., by 
extreme flexion. The head becomes greatly moulded. Cephalhematoma 
may be produced. 

Treatment. In cases which are not very marked, extraction may 
be carried out with forceps. In very marked cases, however, this is 
useless, and may lead to bad lacerations. Pinard's rule is a good one, 
viz., never to overcome bony resistance by forceps-traction. Embryulcia 
or symphyseotomy is then necessary. 

Death of the Fcetus. 

When a foetus dies in utero decomposition changes may cause disten- 
tion of its tissues with gas, and this condition, known as emphysema, may 
delay labor. In such a case it may be necessary to puncture the abdo- 
men, or any part distended, to allow the gas to escape. Rigor mortis 
may sometimes take place in the body and interfere with its quick passage. 

It is to be remembered that absorption from a decomposing foetus may 
hurt the mother. 



ANOMALIES OF THE FCETUS. 



471 



Enlargement of Head or Body by Disease. 

Hydrocephalus. This condition causes delay and trouble in labor, 
varying according to the nature of the hydrocephalus. The head enlarges 
by an accumulation of serum in the ventricles of the brain, especially in 
the lateral ones. Sometimes a collection in the membranes covering the 




Hydromeningocele. (After Herrgott.) 



brain, especially the subarachnoid space, may cause enlargement, and a 
projection may take place through the skull, known as hydromeningocele. 
In the former of these conditions, where the disease is not much devel- 
oped, the bones, fontanelles, and sutures may appear normal, with the 



Fig. 320. 




Encephalocele. (After Vrolik.) 

exception that the bones are thinned, the brain being well formed, but 
large. In more marked cases the ventricles are enlarged, the brain- 
convolutions somewhat obliterated, and the bones of the cranium sepa- 
rated from one another and thinned. The forehead is increased in size 
relative to the face, the frontal bones bulge, and the superciliary ridges 



472 



I'ATI/OIJJCY OF LA HOll. 



are prominent. In the most extreme degree the head is very large, 
being mainly membranous, the brain being represented only l>v a thin 
aao, and by traces of oerebral tissue at the base. Sometimes hydroen- 
oephalooele is formed during the course of enlargement, owing to the 
extension outward, between a deficiency of hone, of the skull contents. 

Spina bifida, or some other malformation, may also occur. Sometimes 
the large sac ruptures, the membranes collapsing and becoming attached 
to the brain structures at the base of the skull (aneneephalus or hemi- 
cephalus). tJydramnios may be present. Breech presentation isfreouent. 

Fig. 321. 




Puncture of spinal canal in a case of hydrocephalus obstructing labor. (After Herrgott.) 



Diagnosis. On abdominal palpation, where the head is distinctly 
enlarged, it may be easily felt. When the breech presents the head is 
found at the fundus uteri. The abdomen may be abnormally distended. 
Per vagtnam, during labor, the wide fontanelles and sutures may be felt. 
Thin parchment-like bones may be distinguished, or a membranous con- 
dition of the vertex may be felt — a fluctuating sac becoming tense 
during the pains. Or islands of bone may be distinguished in the mem- 
brane. Sometimes a hydrocephalus may be present, but the bones may 
be firm and the sutures more or less ossified; in this case it may be more 
difficult to establish a clear diagnosis unless the head is considerably 
enlarged. 

Prognosis. This varies according to the degree and extent of the 



ANOMALIES OF THE FCETUS. 



473 



disease and the nature of the treatment which is employed. The longer 
the delay the greater the risk. Death of the mother may occur from 
exhaustion or from rupture of the uterus. Rupture generally occurs in 
the lower uterine segment, which becomes greatly stretched and thinned; 
but it may take place higher up. Vesico-vaginal fistula may result from 
long-continued pressure. The child very often dies. 

Relation to Labor. Sometimes there may be little delay even 
when the head is large. This is due to softness and compressibility of 
the skull, especially when somewhat macerated or when it is mainly mem- 
branous, and to rupture of the membranous cranial sac. The latter occur- 
rence is most apt to take place when the breech presents. Delay may 
occur at the brim or in the cavity. 

Fig. 322. 




Exomphalos. (After A. R. Simpson.) 



Treatment. Little value need be attached to the life of the child. 
If it does not die in utero, it usually dies soon after birth. 

When the head presents it should be perforated and drained with a 
trocar. When the head collapses, delivery may be effected either by 
version or by embryulcia if the former method be inadvisable. 

If the foetus presents by the breech, either the head may be perforated 
behind the ear, as it lies at the brim, or Tarnier's method may be adopted, 
viz., to open the spinal canal and draw off the fluid by an elastic catheter 
passed through the spinal canal into the head. 



471 



PATHOLOGY OF LABOR. 



In the cases where the sktlll i- enlarged, the hones still firm, and the 

sutures possibly ossified, ii is usually necessary to perform embryulcia. 

Hydrothorax may cause trouble; it is generally associated with ascites, 
anasarca, or other conditions. It may obstruct labor, usually when the 

head ha- passed the brim. It may he necessary to puncture the thorax 

and extract with a cranioclast, reducing the size of the head, if neces- 
sary. Pericardia] effusion may sometimes he very great. 

Ascites i- sometimes met with, and is due to various conditions — c. //., 
abdominal tumors, syphilis. It may he a cause of obstruction, and in some 
cases a very marked one. As soon as the condition is diagnosed the size 
of the swelling should he reduced. This may he carried out by direct 
puncture of the abdomen. But it may be necessary to reach this part 
through the thorax. If a large tumor exists, it may be necessary to 
break it up or remove it. 

Fig. 823. 




Sacral tumor. (Keller: Mutter Museum, College of Physicians.) 



Distention of the Ureters and Hydronephrosis are rare. 

Dilatation of the Bladder. This condition is occasionally found. The 
urethra may or may not be imperforate. The foetus is rarely born alive, 
or, if living, soon afterward dies. It may sometimes be associated with 
ascites. 

Dilatation of the Uterus, the cervix being closed, is very rarely found. 

General (Edema of the body is occasionally met with. 

Abdominal Intrafoetation has been reported. In this condition the abdo- 
men contains another foetus, or part of one, which causes enlargement. 



ANOMALIES OF THE FCETUS. 



475 



Umbilical Hernia, or hernia through some other part, may lead to ob- 
struction in labor. 

Exomphalos may cause delay. 

Tumors of the liver, kidney, spleen, pancreas, and other viscera, some- 
times occur. 

Hydrorrhacis. This usually occurs with spina bifida. It is a collection 
of fluid in a sac composed of the spinal membranes and skin, and is 
usually in the coccygeal or sciatic region. The swelling varies; it may 
be very large. 

Fig. 324. Fig. 325. 








Congenital elephantiasis. (After Stein wiekee.) 



CEdema of foetus. (After Betschlee.) 



Tumors of various kinds, simple or malignant, may obstruct delivery — 
e. g., cystic, vascular, fatty, cartilaginous, bony, sarcomatous, carcinom- 
atous, teratomatous. Most frequently they are found in the region of 
the sacrum and coccyx — e. g. y cystic hygroma. The neck is also an occa- 
sional seat of a growth. They are, however, found in every region of 
the body. 

Treatment. The general treatment for these conditions is as fol- 
lows : When the swelling is only slight, delivery may be effected by 
forceps or version; if the breech present, by traction and pressure from 
above. 

If too large for delivery, puncture of the swelling or reduction by 
embryulcia and evisceration are necessary. Thus, if, in a head presen- 
tation, the abdominal swelling cannot be reached without opening the 
thorax, the latter procedure should be carried out. It may even be 
necessary to reduce the head in size or to amputate it in order to get 
room. Sometimes the swelling bursts of itself. 

The following very rare conditions sometimes cause obstruction, viz., 
anchylosis of joints, adhesions of limbs to the body, anchylosis of foetus 
to placenta or uterus. 



47»; PATHOLOGY OF LABOR. 



Plural Births. 



Twins. Relation to Labor. En a large percentage of cases twin 
labors arc easy and ud complicated. After the birth of the first child the 
second follows, there being an interval between, usually of less than an 
hour in extent, though it may be longer. The placenta? are generally 

delivered after the second child. Sometimes the first child may he fol- 
lowed hv its own placenta. Sometimes the second placenta precedes the 
second child. Where the placenta is a large Single one, it follows the 
birth of both foetuses, though sometimes a portion may be torn oft' and 
expelled with the first child. 

The following percentages are given by Spiegelberg to show the rela- 
tive frequency of the presentations met with : 

Both heads presenting, 49 per cent. 

Head and breech, 31.70 per cent. 

Both breech presentations, 8.60 per cent. 

Head and transverse, 6.18. 

Breech and transverse, 4.14 per cent. 

Both transverse, 0.35 per cent. 

The pains may be weak in twin cases, owing to the overstretching of 
the uterus, and there may be trouble in the third stage from this reason 
also. Hydramnios may be present. In some cases this may be found 
only in one amniotic cavity, oligohydramnios being the condition in the 
other. 

Prognosis. The mortality of the children is considerably greater 
than in single births. This is due to various causes. The labors are 
often premature and the foetuses, consequently, in an undeveloped state, 
one being usually weaker and smaller than the other. Malpresentations 
and malpositions are frequent, necessitating artificial delivery. The ma- 
ternal risk is also considerable. This is due to the delay which is often 
present as a result of w T eak pains; albuminuria is often found; eclamp- 
sia is more frequent than in single births; there may be trouble in the 
third stage from the large placenta, and from inertia uteri; post-partum 
hemorrhage may occur; there is a greater risk of septic absorption in 
the puerperium. If there is complete obstruction to the passage of the 
twins, the patient may die of exhaustion or of rupture of the uterus. 
Then there are risks attendant upon operative interference. 

Management of Labor. After the birth of the first child the cord 
must be tied in two places and divided, lest there be communication 
between the placental circulations and the second child should bleed to 
death. The uterus should then be gently kneaded through the abdom- 
inal wall to favor its retraction. There is a difference of opinion as to 
how long a time should elapse between the birth of the first anoj that of 
the second child. Our opinion is that it should not be prolonged, for, 
though the mother may gain strength, retraction and contraction of the 
cervix may occur. If the second child is transverse it should be turned. 
This may often be done by external manipulations. While the second 
child is being born a hand should be kept on the abdomen following the 
uterus. After this child is born the hand should hold the fundus uteri 
until the placenta is delivered. If there should be partial separation of 
the placenta and hemorrhage, the uterus should be emptied artificially. 



ANOMALIES OF THE FOETUS. 477 

If there is inertia of the uterus special care must be taken, according to 
the methods described on page 405. 

When the second child is discovered only after the birth of the first, 
the mother should not be informed, lest the shock should inhibit uterine 
action. 

If, after the birth of the first child, an hour elapses without the delivery 
of the second, the second bag of membranes, if there be one, should be 
ruptured, and the child delivered by version or forceps. 

In some cases it may be necessary to deliver the second child much 
earlier — e.g., if both placentae should be born before it, or if there should 
be much hemorrhage following the birth of the first child. 

Fig. 326. 




Locked twins. 

Complex Cases. 1. Sometimes labor may be delayed by the presence 
in the dilating cervix of two bags of membranes. When dilatation is 
complete the bag of the leading child should be ruptured. 

2. Where both presenting parts tend to enter the brim together, one 
should be pushed up to allow the other to engage. Where the head of 
one and the breech of the other are so j)laced, the head should be allowed 
to engage. 

3. Interlocking Twins. In some cases the twins may become locked. 
This may happen in two ways : 

(a) Where both heads present, the second may enter the pelvis after 
the first and jam against the neck or thorax. The heads must, of course, 
be small to permit this complication. 

Treatment. The most advanced head should be delivered with for- 
ceps, and then the other should be delivered. 

Sometimes embryulcia of one is necessary. This should be performed 
on the first child, because the second is more likely to be alive, there 
being less risk of compression of its cord. 



m 



PATHOLOQ V OF LABOR. 



(6) Jn Borne cases where one child presents by the breech and the other 

by the head, the former may be delivered a> far as the neck, but no 

farther, because the head of the second child has locked with that of the 
first; this may take place by overlapping of the chins, or of the occipital 
regions, or tin- face of one may he pressed against the hack of the neck 
of the other. This locking occurs in the pelvis. 

Treatment. Sometimes the head of the second child may be pushed 

up. If this is impossible, and nature cannot soon bring about delivery, 
the head of the second child may he delivered hv forceps. If this is 
impossible, <>r if there is great difficulty in applying the blades, embry- 
ulcia should he performed on the head of the child which is dead. In 
almost every case this is the breech-first child. After the extraction of 
the mutilated child the other may be delivered. 



Fig. 327. 




Prosopothoracopagus. 

4. Interlacing and Knotting of the Umbilical Cord. This may occur 
where there is only one amniotic sac. The cords may be twisted around 
one another in various ways, or even knotted. If this happens early in 
pregnancy there is great probability that death of one or both twins will 
occur and premature labor be induced. It may, however, be found at full 
time. As labor proceeds one cord may drag on the other and imperil 
circulation. 



ANOMALIES OF THE FCETUS. 479 

Treatment. If after delivery of the first child the condition is 
diagnosed, the second child should be delivered at once by version or 
turning. 

Fig. 328. 




Derodyrne or derodidyme. (After Ahlfeld.) 

Triplets. The greater the number of foetuses the greater the tendency 
to prematurity of delivery. Consequently, the labors may sometimes be 
comparatively easy. Sometimes, however, they are considerably pro- 
longed. The first stage is usually longer than normal. 

Albuminuria is more frequent; also inertia uteri and hemorrhage during 
or after labor. In 458 triplet cases collected by Charbonnier there were 
254 head presentations, 117 breech, and 57 transverse. According to 
this author there is a very small percentage of cases in which malpre- 
sentation and malpositions have caused serious trouble. The third stage 
must be very carefully attended to. Generally the three foetuses precede 
the placentae. Sometimes, however, each is followed by its own. Some- 
times there are two foetuses, then one or two placentae, followed by the 
third foetus and its placenta. Sometimes one foetus and its placenta are 
first, then the other two and their placentae. 

Monstrosities. 

Anencephalus or Hemicephalus. In this form the neck is short and the 
shoulders may be very broad. 

Delay in labor is caused by the bad action of the deformed head as 
a dilator, by the breadth of the shoulders, or by the entrance into the 



480 



PA THOLOQY OF LABOR. 



brim <>f the small head along with other parte of the foetus. Turning 
should be employed if the case be diagnosed early enough. 

A.oardiacus is another rare monstrosity which may interfere with labor. 

Double Monsters. These may be considered In three main groups: 
1. Those in which there is double formation in the upper part of the 
body — c g. y a two-headed monster. 

'2. Those in which there is double formation of the lower part. 
ft. Those in which there are two heads and two bodies: 

(a) Those in which the backs are united. 

(b) Those in which the bellies are united. 



Pig. 82fl. 




Ischiopage. 

Diagnosis. This may be very difficult during labor. It can be best 
arrived at when the hand is passed into the uterus. Double monsters 
are apt to be mistaken for twins. 

Relation to Labor. In many cases these monsters are delivered 
naturally, probably because the foetus is usually small. 

Where two heads present they may be born, but perforation or decapi- 
tation of one or both may be necessary. 

In some cases, where the head is single, forceps may suffice to aid 
delivery. In some cases it may be necessary to reduce the size of oue 
or both trunks. Version may sometimes be employed with advantage. 



CHAPTER XXI. 

ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 

Prolapsus Funis. 

In this accident a loop of the umbilical cord slips down alongside the 
presenting part or in advance of it. As the labor progresses the dis- 
placed portion of the cord is exposed to strangulation by pressure between 
the presenting part and the walls of the birth-canal. Unrelieved, the 
complication, as a rule, results in the death of the foetus within a few 
moments by interruption of the foeto-placentai circulation. In excep- 
tional instances the cord may escape injurious pressure and the child be 
born alive. This is possible when the pelvis is roomy and the expulsion 
of the foetus is accomplished in one or two pains. Prolapse of the cord 
may take place before labor begins, but in the majority of cases does not 
occur till the cervix is well dilated. Ordinarily the two halves of the 
prolapsed cord lie in apposition, but occasionally the presenting portion 
of the child may intervene. Thus in vertex presentation the loop may 
extend upon opposite sides of the head, and in shoulder and footling 
presentation may include an arm or a leg. The prolapse occurs most 
frequently at one side of the promontory, rarely along the lateral wall of 
the pelvis, and still more rarely near the median line in front. 

When the prolapse is within the bag of waters, it is sometimes spoken 
of as a presentation of the funis. 

Frequency. The frequency of this accident is about 1 in 250 labors. 
According to Winckel, it happens once in from 65 to 500 cases. In 
a collective investigation by Churchill, prolapse of the cord was re- 
ported 852 times in 91,000 births, an average of 1 in 107 cases. The 
complication is met with most frequently when an extremity presents, 
next in order of frequency in breech, and last in vertex presentations. 

Etiology. The essential cause of prolapse of the cord is failure of the 
presenting part of the foetus to fill completely and continuously the lower 
uterine segment. Conditions, then, which may give rise to this lack of 
close approximation are the predisposing causes of prolapsus funis. They 
are: narrow pelvis, which may act not only by hindering the adaptation 
of the head to the passages, but by favoring the occurrence of malpre- 
sentation; uterine myomata; diminished size and consequent mobility 
of the foetus, favoring malpresentation and malposition; abnormal pre- 
sentations, especially breech, shoulder, footling, and face presentations; 
excessive amount of liquor amnii, causing preternatural mobility of the 
foetus; low implantation of the placenta; marginal insertion or excessive 
length of cord; twin pregnancy; multiparity, owing to relaxation of the 
abdominal walls and to uterine obliquity, especially to pendulous abdomen. 

An important exciting cause is premature rupture of the membranes 
and the sudden escape of a large amount of amniotic fluid, particularly if 
the woman be standing; the escaping fluid may sweep out a loop of the 

31 ( 481 ) 



lSi> PATHOLOGY OF LABOR, 

cord in front of the presenting part of the child. Violent movements 
on t lie part of the mother favoring recession of the foetus from the Lower 
uterine Begment and the gravitation of the cord may be included 
among the possible factors in bringing about the displacement, Attempts 
at version by unskilled operators are sometimes responsible for the pro- 
lapse. 

Diagnosis. The examination should be made between the pains. The 
condition can scarcely be recognized before the os has dilated, the mem- 
branes being still intact. It may rarely be possible, if the lower uterine 
segment is thin, to detect, with the examining finger at the utero-vagiual 
junction, the pulsation of the cord. It is distinguished from maternal 
pulse by the count. If the os is sufficiently dilated to admit the finger, 
the cord may be felt when it lies well down in the membranes. Yet it 
may escape 1 detection, owing to the facility with which it recedes from the 
examining linger. When the foetus is dead, pulsation is, of course, 
absent. The absence of pulsation, however, can be taken as evidence of 
foetal death only when persistent for ten or fifteen minutes. The funic 
pulse may be interrupted temporarily by compression of the cord between 
the pelvic brim and the presenting part. Fingers and toes are distin- 
guished from the cord by their anatomical characters. Foetal parts, too, 
will sometimes be drawn up when touched. The prolapsed cord should 
not be mistaken for intestine. The latter is recognized by the mesentery 
and by the absence of pulsation. It is larger than the cord and not so 
firm in consistence. After the membranes have ruptured and the cord 
protrudes into the vagina, the diagnosis presents no difficulty. The pres- 
ence or absence of pulsation should always be noted, to determine whether 
the child is living or not, since this question will obviously have an im- 
portant bearing on the treatment. Should the displaced loop be caught 
between the presenting part and the sides of the pelvis, but fall no 
farther, the condition may escape detection and the child be asphyxiated 
before the cause is discovered. Winckel says that when the foetal heart- 
sounds grow continually feebler and no cause is apparent, prolapse of the 
funis should be suspected, and the physician should act accordingly. 

Prognosis. In general this complication of labor has, per se, little 
influence upon the mother. The treatment necessitated in the interest 
of the child frequently subjects the woman to the risk of shock, hemor- 
rhage, and sepsis usually attendant upon forced delivery. For the child 
the prognosis is exceedingly grave. More than half the children die of 
asphyxia. Churchill places the infant mortality at 53 per cent., Scanzoni 
at 58 per cent. Depaul, in 143 cases, had ninety -six deaths. The prog- 
nosis, however, must necessarily vary with the conditions of the case, 
such as the position and presentation of the foetus, the degree of displace- 
ment, the part of the pelvis at which it occurs, the size of the cord, and 
the duration of the prolapse. Prolapse of the cord in vertex and in 
breech is more surely fatal to the foetus than in other presentations, since 
the presenting part more completely fills the pelvis and the cord is more 
certainly strangulated. The risk to the foetus is comparatively small 
while the membranes are intact. The possibility of escaping injurious 
pressure is obviously greater when the cord lies in that part of the pelvis 
in which there is most room. The size of the cord has some influence, 
since the thicker the cord the greater the amount of Wharton's jelly and 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 483 

the consequent protection of the vessels. With primiparae, in whom the 
passages are more unyielding and the labor more prolonged, the foetal 
mortality is greater than with women who have borne children. 

Treatment. When the child is surely dead or non-viable, the reposi- 
tion of the cord is obviously not called for. 

Before Rupture of Membranes. When the child is living and the mem- 
branes are unruptured, the latter should, if possible, be preserved. It 
should be a general rule before rupturing the membranes in any case to 
first examine for possible prolapse of the cord. For reduction of the 
displacement, while the bag of waters is still intact, postural measures 
should be tried. Harm can seldom come to the foetus from the prolapse 
so long as waters have not escaped. The woman is required to lie on 
the side opposite that on which the cord has come down. Gravity thus 
favors the return of the prolapsed loop. The reposition may be assisted, 
if need be, by gently pushing up the cord between the pains, with care to 
avoid breaking the membranes. Should this fail the woman may be 
placed in the knee-chest position. In this posture the inverted axis of 
the uterus is nearly vertical, and gravity acts at the greatest advantage. 
The Trendelenburg posture may serve as a convenient substitute for the 
latter position. While not so effectual as the knee-chest, it is more so 
than the lateral posture; the inclination should be about 45 degrees. The 
foetal heart is to be listened for at short intervals. The cord once repos- 
ited, to prevent recurrence of the prolapse the presenting part should be 
crowded into the excavation and firmly held there till engaged. 

After Rupture of the Membranes. If the foetal pulse can be felt, the 
cord should be replaced, if possible. If pulsation has ceased and the 
foetal heart is still beating, the presenting pole of the foetus should be 
pushed up and the cord reposited after pulsation returns. Two methods 
are available — the manual and the instrumental. Either is to be under- 
taken with the aid of posture and generally of anaesthesia. The knee- 
chest, the Trendelenburg, or even the lateral position, with the hips 
strongly elevated, may be chosen. The first is the most effectual, but is 
not always practicable, under anaesthesia, without the aid of skilled 
assistants. 

Manual Method. It must be remembered that much handling of 
the cord enfeebles the circulation and endangers the life of the child. 
The cord should be gently drawn to the front of the pelvis, where the 
reposition can most easily be effected. It is seldom that the prolapsed 
loops can be caught up in the hand and returned into the cavity of the 
uterus, or even pushed up inch by inch; as fast as one part is reposited 
another comes down. Yet success is sometimes possible by either of 
these plans. A method which has rarely failed in the writer's hands is 
this : The prolapsed loop is loosely twisted into a rope with great care to 
avoid interference with the circulation. It can then readily be replaced 
within the uterus. For retention, the woman may be kept in the latero- 
prone position, or the presenting pole be held in the brim till engaged. 
Occasional examinations are made per vaginam to make sure that the 
cord has not again slipped down. The foetal pulse-rate is listened for at 
frequent intervals. 

Instrumental Method. A suitable instrument for repositing the 
prolapsed cord may be improvised with a large English catheter and a 



484 



PATHOLOGY OF LABOR. 



few feel of tape A loop of the tape is made to encircle the cord loosely, 
ami it- free ends arc attached to the tip of the catheter. The repositor, 

with a Btylet inserted, IS pushed into the uterus well up to the fundus, 

carrying the cord with it. The stylet is withdrawn and the catheter hit 
to be expelled with the child. If preferred, the tape may be secured to 

the catheter hv a knot, which can he untied by pulling 0D the free end 
of the tape, and the cord thus set free. The instrument may then be 
withdrawn. Return of the prolapse is prevented by pressure over the 
fundus, holding the presenting pole in the brim till firmly engaged. 

Version or Forceps. Attempts at reposition failing, if the child is still 
living, immediate resort should be had to version or forceps. It is some- 
times possible to save the child by rapid delivery without replacing the 
funis. The cord should first be disposed in front of that sacro-iliac joint 
opposite which there is most room. 



Inversion of the Uterus. 

Inversion of the uterus may be complete or partial. In complete 
inversion the organ is turned inside out and upside down. In partial 
inversion it presents a cup-shaped depression of greater or less depth at 
the fundus. 



Fig. 330. 



Fig. 331. 





Beginning inversion of uterus, placenta 
attached. (Modified from Ribemont-Des- 
saigxes and Lepage.) 



Cup-shaped depression of fundus. (Modi- 
fied from Ribemont-Dessaignes and Le- 
page.) 



Frequency. Fortunately this accident is exceedingly rare. Winckel 
had never seen a case of complete inversion of the uterus in 20,000 cases 
of labor, nor had Braun in 250,000. In 192,000 labors at the Rotunda 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 485 

Hospital in Dublin, covering a period of nearly a century, one case was 
reported. The accident is doubtless more frequent in private than in 
hospital practice. Kehrer says it is believed to occur once in 2000 labors. 
Inversion of the uterus seldom takes place except at term, yet we have 
records of cases complicating miscarriage at six months, and Woodson 
reports a complete inversion following miscarriage at four months. 

Varieties. The inversion may be acute or chronic. The latter variety 
concerns the gynecologist rather than the obstetrician, and will not be 
discussed in this connection. Three degrees of acute inversion are recog- 
nized : 

1. A cup-shaped depression of the fundus, the latter approaching but 
not engaging in the os uteri. (Fig. 331.) 

2. Partial inversion, the fundus protruding from the os. This is a 
true intussusception. (Fig. 332.) 



Fig. 332. 



Fig. 333. 





Partial inversion of uterus. (Modified from 
Ribemont-Dessaignes and Lepage.) 



Complete inversion of uterus. (Modified from 
Ribemont-Dessaignes and Lepage.) 



3. Complete inversion (Fig. 333). In the latter variety, the uterus 
being turned inside out, the body of the organ may project from the 
vulva, appearing as a rounded mass between the patient's thighs. In 
the funnel-shaped depression formed by the inverted uterus may be 
found, in addition to the appe adages, small intestines and a portion of 
the omentum. 

Etiology. Much discussion has arisen among writers as to the causes 
and mechanism of inversion of the uterus. One factor of paramount 
importance, and in the absence of which inversion is practically impos- 



486 PATHOLOQ F OF LABOR. 

Bible, i- atony or paresis of the uterine muscle. In an exhaustive article 
on this subject Crampton arrives at the following conclusion: {t [nver- 
sion of the uterus is preceded by paresis of some portion of the uterine 
muscle, not necessarily at the placental site, the main causes being too 
frequent child-bearing, tedious labors, precipitate labors, repeated miscar- 
riages, and traumatism." For traction on the cord to produce inversion 

there DlUSl be some attendant paresis. In the absence of inertia the cord 
would break under the strain necessary to invert the uterus. Inversion 
may take place in sudden or unexpected delivery while the woman is 
in the standing position. The accident is most liable to occur either at 
tin' moment the child is born or during the third stage of labor. Inver- 
sion of the uterus may originate in any of the following ways : 

1. The inversion may be spontaneous. When the placental attach- 
ment is at the fundus a temporary atony of the uterine muscle at 
this point may cause a dipping down of the fundus, and the beginning 
inversion may be increased by the weight of the placenta if still attached, 
and of the abdominal viscera pressing upon the fundus from above. 
(Fig. 330.) The inverted portion now acts as a foreign body, and being 
firmly grasped by the non-paralyzed segment of the uterus, it is carried 
further down at each contraction of the organ. A similar phenomenon 
is observed in intussusception of the bowels. Inversion arising in this 
manner is most likely to be incomplete. 

2. The accident may be caused by unskilful pressure of the obstetri- 
cian's hand on the fundus. Instances have been reported in which inver- 
sion of the uterus was produced by attempts at expressing the placenta 
directly after the completion of the second stage of labor. If, before 
sufficient time has elapsed for contraction to occur, forcible pressure be 
made on the fundus, inversion may result. Among the medical writings 
of the ancients mention is made of uterine inversion induced in this 
manner. 

3. A common cause is believed to be traction upon the cord in the 
endeavor to remove the placenta shortly after the child is born. The 
relaxation of the uterus usually present at this time favors the inversion. 
In exceptional instances of short cord the fundus may be dragged down 
by the tension put upon the cord as the child is expelled. 

Symptoms. The usual symptoms of inversion of the uterus are shock, 
pain, hemorrhage, and vesical and rectal tenesmus. The intensity of 
the symptoms, however, varies greatly in different cases. Ordinarily the 
pain is severe. It comes on abruptly, and is referred to the lower abdo- 
men and the pelvis. The abdomen is painful to the touch. The hem- 
orrhage may or may not be profuse, according as the inverted uterus is 
relaxed or firmly contracted. In exceptional cases it is insignificant; 
generally it is excessive. In the latter event the symptoms of acute 
anaemia are present. 

The vesical and rectal symptoms are sometimes wholly absent. Occa- 
sionally there is retention of urine. Reeve reports two cases of complete 
inversion in which there was nothing in the patient's appearance or his- 
tory to excite suspicion of the accident. Jewett has published a similar 
case. 

Diagnosis. As a rule, the acuteness and severity of the symptoms are 
such that they can scarcely fail to arrest the physician's attention should 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 487 

he be present when the inversion occurs. The diagnosis, however, must 
rest mainly on the physical signs. These are essentially the absence of 
the usual abdominal tumor, the presence of an intravaginal tumor, and 
the character of the tumor. It is indispensable to a satisfactory physical 
examination that the bladder and the rectum be empty. If the examiner 
be expert, the absence of the uterus in the abdomen may be determined 
beyond all possibility of doubt by the combined abdominal and vaginal, 
followed, if necessary, by the abdomino-rectal examination. The pres- 
ence of the tumor in the vagina is obvious to the touch, sometimes to the 
eye. It must, however, be differentiated from a uterine polypus. The 
distinguishing points are the following: The inverted uterus presents a 
funnel-shaped depression at the cervix, which may generally be made 
out with one hand over the abdomen, the other making counter-pressure 
over the tumor within the vagina. If the inversion has existed for 
several days the abdomen may be too tense and too tender for satisfactory 
palpation ; but this difficulty may be overcome by anaesthesia. In uterine 
inversion the implantation of the pedicle is circular, while in a polypus it 
is lateral. In the latter condition a uterine sound may be passed by the 
side of the pedicle into«the uterine cavity, while in the former the sound 
will be arrested at the root of the pedicle. Sometimes it is possible by 
inspection with the aid of the speculum to detect upon the surface of the 
tumor the openings of the Fallopian tubes. The special contractility of 
the uterus may aid in differentiating. The possible presence of the 
placenta still adherent to the uterus must be borne in mind. Distinction 
from a polypus, however, is sometimes difficult. 

Prognosis. Inversion of the uterus is among the most formidable com- 
plications of childbirth. Death may occur within a few hours from 
hemorrhage and shock, or later from septicaemia. Rarely a chronic 
inversion may exist for months or years. In exceptional instances spon- 
taneous reposition has taken place, and recovery has been known to fol- 
low the separation of the organ by sloughing. The total mortality may 
fairly be stated at from one-quarter to one-third. 

Treatment. Prophylaxis. Puerperal inversion of the uterus is gen- 
erally, if not always, a preventable accident. It is scarcely possible under 
a proper management of the third stage of labor. The prophylaxis con- 
sists in the avoidance of traction upon the cord while the uterus is 
relaxed, and of manipulation which may indent the fundus, and finally 
of properly directed efforts to bring about a prompt and persistent retrac- 
tion of the uterus. If the uterus is intelligently watched, with the hand 
on the abdomen over the anterior surface of the fundus, from the moment 
the child is expelled till retraction is complete the slightest depression at 
the fundus may immediately be detected and reduced. Failure to con- 
tract normally can usually be corrected by friction or by compression 
with one or both hands. 

Reposition. There are three methods of employing taxis in the reduc- 
tion of a recent inversion of the uterus. The first consists in grasping the 
fundus of the uterus in the hollow of the right hand and making gentle 
but firm pressure upward in the axis of the pelvis. While making press- 
ure from below with the palm of the hand, an equal pressure should be 
exerted laterally with the thumb and finger, the object sought being to 
return first that portion of the uterus through the constricting ring which 



l,ss PATHOLOGY OF LABOR. 

emerged last. Care should be taken to direct the pressure toward one 

siilr in order t<> avoid the promontory of the sacrum. At the same time 
counter-pressure should be made and the constricting ring dilated with 

the left hand al>ove the pubes. 

The second method consists in making direct upward pressure upon 

the fundus of the litems. Tuder this plan, if it succeed, that portion of 
the uterus which emerged first through the constriction is first returned. 

The third method consists in making alternating pressure near the ori- 
fices of the oviducts with the thumb and fingers. As a rule, the induction 
of the inversion by whatever method is to be undertaken only with the 
aid of an anaesthetic. 

Reposition being complete, the hand is kept within the uterus for 
several minutes till a contraction occurs. To excite uterine contraction 
and stop the bleeding, ergot or ergotine is administered subcutaneously. 
Putting the child to the breast may help, or an intra-uterine douche of 
sterilized water, at a temperature of 110°, may be given. Rarely will 
it be found necessary to tampon the uterus with iodoform gauze. 

Should the placenta be attached to the inverted uterus, it should gen- 
erally be separated before repositing, especially if it be partially detached. 
When inversion has existed for several days or more, attempts at reduc- 
tion may still be made, but with much less prospect of success than at 
the close of labor. In such cases, before taxis is tried, a rubber bag may 
be introduced into the vagina and distended with water. After eight or 
ten hours the bag is removed and taxis tried. 

The taxis may be repeated at intervals of six or eight hours, elastic 
pressure with a water-bag being maintained during the intervals. In 
difficult cases advantage may be taken of the knee-chest or the Tren- 
delenburg positions. It is scarcely necessary to say that all manipula- 
tion or instrumentation within the vagina must be conducted under a 
strict asepsis. Extreme measures must be avoided during the puerpe- 
rium, and attempts at reposition are best postponed for three or four 
weeks, should they not prove successful within twenty-four or forty-eight 
hours. 

If the uterus is infected early amputation is generally advisable. But 
hysterectomy, together with the treatment of chronic tumors, belongs 
more properly to the province of the gynecologist. 



Rupture of the Uterus. 

Rupture of the uterus may occur in any portion of the organ, and 
during gestation, labor, or the puerperium. Laceration of the infra- 
vaginal portion of the cervix is an accident of little consequence; indeed, 
a tear of greater or less extent is apt to occur in all first labors. These 
lacerations are discussed elsewhere. Of an entirely different character 
are ruptures of the supravaginal portion of the cervix or of the body of 
the uterus. While spontaneous rupture of the uterus may take place in 
the later months of gestation or during the puerperal period, the vast 
majority of ruptures occur during the second stage of labor. In this con- 
nection will be discussed more especially ruptures of the body of the 
uterus occurring during childbirth. 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 489 

Frequency. Fortunately, uterine rupture is a rare accident. The fre- 
quency may be stated at one in about 4000 labors. Churchill, however, 
gives the proportion as 1 in 1331, Bumm 1 in 940, and Jolly estimates, 
from nearly one million cases, that the accident occurs once in 3400 
labors. The latter authority found that in 573 cases of rupture of the 
uterus, 376 were spontaneous and 197 were traumatic. 

From the extreme reluctance which practitioners naturally have for 
publishing cases of this unfortunate accident occurring in private practice, 
estimates of its frequency must be derived mainly from the records of 
the large hospitals. The percentage is large in countries where rachitis 
and osteomalacia are prevalent, pelvic deformity often being the predis- 
posing cause of rupture of the uterus. 

Pathological Anatomy. While rupture of the uterus may involve any 
portion of the organ, it usually begins in the inferior segment. This is 
accounted for by the greater distention and consequent thinning to which 
this portion of the uterus is subjected during labor, especially in labors 
attended with violent uterine contractions. The anterior and the poste- 
rior wall of the lower uterine segment, too, are exposed to injury by 
pressure between the bony prominences of the sacrum behind, or of the 
symphysis in front, and the child's head. Sometimes the vaginal por- 
tion of the neck is torn away in the form of a ring before the advancing 
head. Most frequently the seat of rupture is lateral. When rupture 
occurs at or near term, and is due to external violence, the superior por- 
tion of the anterior wall is usually the location of the injury. When 
the uterus is the seat of a neoplasm, either benign or malignant, the elas- 
ticity of that portion of the organ which is diseased is diminished, and 
rupture may occur along the edge of the degenerated tissue. Some 
authorities hold, however, that this want of elasticity affords greater 
resistance to intra-uterine pressure, and that, consequently, when the 
uterus is ruptured, the portion involved in the new growth is the last to 
give way. 

The extent, direction, and shape of the tear are subject to the widest 
possible variation. The extent of the injury varies in different cases 
from a small rent scarcely large enough to admit the finger tip to a 
laceration permitting the escape of the child and placenta into the abdom- 
inal cavity. The direction is most frequently vertical, sometimes trans- 
verse or oblique. It may involve the entire length of the uterus; 
frequently it invades the vagina, and in exceptional instances the bladder. 
Transverse tears may extend through the circumference of the organ. 
Rarely the tear is even and clean cut. Usually the edge of the wound 
presents a jagged and irregular appearance, owing to the contractility of 
the muscular fibres of the uterus. 

If the patient survives the accident for forty- eight or seventy-two 
hours, there may be found post mortem a large quantity of blood in the 
abdominal cavity; indeed, the hemorrhage is often the cause of death. 
The tissues around the margin of the wound are frequently swollen and 
ecchymosed, presenting all the evidences of acute inflammation, or there 
may be patches of necrotic tissue. Where the uterus was primarily the 
seat of lesions favoring rupture, evidence to that effect will be observed. 

The rupture may be complete or partial. In complete rupture the tear 
involves both the muscularis and the peritoneum, opening the perito- 



.|(, (l PATHOLOGY OF LABOR. 

ileal cavity; in inoompleU rupture the laceration extends through the 
muscular wall only, the serous covering remaining intact. The laxity 

with which the peritoneum is attached to the inferior wall of the litems 

makes it possible for a rupture beginning in the supravaginal portion 

of the neck t.» extend upward for a considerable distance in the muscular 
layer of the uterus without laceration of its serous covering. Most £re- 
quently the tear in the serous covering takes place at the insertion of the 
broad Ligament. In subserous Lacerations a large effusion of blood may 
accumulate at the scat of the rent without the peritoneal cavity. It is 
stated that the peritoneal coat may be ruptured, the muscular layer 
remaining intact. This form of laceration is possible during either preg- 
nancy or labor when from any cause elasticity of the peritoneum has been 
impaired. In these rare instances hemorrhage and diffused peritonitis 
result. 

Etiology. The causes of rupture of the uterus are: I. Predisposing, 
and II. Determining. 

I. Predisposing Causes. The first predisposing cause is pregnancy, 
together with the changes undergone by the uterus at this time. During 
pregnancy and at term the uterus becomes greatly distended, and its walls 
are softened and thinned. Conditions which lead to excessive distention 
of the uterus are hydramnios, multiple pregnancy, hydrocephalus, and 
those which lessen the resistance of the uterine walls. Multiparity, late 
pritniparity, or systemic disease may act as predisposing causes. Accord- 
ing to the statistics collected by Brand, of 546 cases of rupture, only 64 
occurred in primiparse. Since male children are ordinarily larger than 
female, sex, as suggested by Keever, may be a predisposing factor. He 
found that in twenty cases of rupture three-fourths were male children. 

The influence which various degenerations of the uterine wall may exert 
as predisposing causes of rupture is undoubtedly great, though clinical 
evidence to this effect is necessarily meagre. Traumatism of various sorts, 
as blows, falls, kicks, etc., may weaken the wall of the uterus at the site 
of injury. The muscular fibres of the uterus may be the seat of degen- 
erative changes, calcareous, fatty, or apoplectiform conditions which 
favor rupture. The weak point may be in the scar left by a former 
Csesarean section. Malignant disease of the uterus exposes to rupture. 
It apparently makes little difference whether a softening or ulceration 
result, or, on the contrary, the tissues affected become hard and cirrhotic. 
In the former case, when rupture occurs, it will take place through 
the neoplasm, and, in the latter instance, at or near the junction of the 
healthy with the diseased tissue. A large growth in the uterus, as a 
submucous fibroid, may by its mechanical presence offer an obstacle to 
the expulsion of the child, and thus favor rupture. Malformation of the 
uterus predisposes to this accident. Rarely the uterus is perforated in 
cystic degeneration of the chorion. Pelvic deformity is one of the most 
common of the predisposing causes of uterine rupture. 

Other conditions which give rise to disproportion between the foetus 
and the birth-canal, or which obstruct the birth, may predispose. As 
examples, may be cited malpositions or malpresentations of the foetus; 
the resistance offered by a rigid os, whether due to spasm or to malignant 
disease, and marked uterine obliquity. While rupture of the uterus 
rarely occurs before the membranes have broken, a case is recorded by 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 491 

Hamilton in which at the autopsy the lateral wall of the uterus was 
the seat of a tear of considerable extent, the membranes still being intact. 
Rupture of the puerperal uterus is due to sloughing or to a dissecting 
metritis. 

II. Determining Causes. The determining or exciting causes of 
rupture of the uterus may conveniently be grouped under two heads — 
traumatism and excessive uterine contraction. Examples of the former 
class are blows, falls, and kicks. The prominence of the uterine tumor 
at term increases the risk from external violence to which persons in all 
walks of life are daily exposed. Rupture occurring from these causes 
concerns the general surgeon rather than the obstetrician. Of much 
more frequent occurrence is rupture from unskilful attempts at version, 
the high application of the forceps, prolonged attempts at separating a 
firmly adherent placenta, and other obstetric operations. Hess, from an 
extended experience, believes that spontaneous rupture of the uterus is 
an accident of great rarity, whereas the lacerations produced by rough 
manipulations are comparatively common. Probably the most impor- 
tant element in determining a rupture is excessive uterine retraction. 
The researches of Bandl, first published in 1875, have added much to 
our knowledge of this subject. He showed that the upper two-thirds 
only of the uterus is the contractile portion, the lower third taking no 
direct part in the expulsion of the foetus. As labor progresses the upper 
portion of the uterus becomes thicker with each contraction, while the 
lower portion grows thinner and more distended. At the junction of 
the upper and lower segments there is formed a well-marked line of 
demarcation, which occasionally can be felt through the abdominal wall, 
the " contraction or retraction ring." Normally, at each contraction 
the uterus tends to rise slightly toward the diaphragm, the lower seg- 
ment becoming more distended, and receding somew T hat as the presenting 
part of the foetus advances. This to-and-fro motion of the uterus, with 
a slight advancement of the foetus at each contraction, prevents undue 
stretching of the lower segment. If now the presenting part meets with 
obstruction, as in contracted pelvis, or a shoulder presentation, or pelvic 
tumor, the foetus not advancing, the lower segment of the uterus becomes 
abnormally distended until finally, under the influence of an unusually 
forcible contraction, rupture occurs. There can be no doubt that the 
injudicious exhibition of ergot in such cases has, not infrequently, been 
the cause of rupture. Meigs has seen three cases, and Bedford four, trace- 
able directly to this cause. Jolly collected thirty-three cases of uterine 
rupture in which ergot was given in large doses. In all cases of dispro- 
portion, whether referable to the foetus or to the birth-canal, rupture is 
caused in one of tw r o ways: either as the direct result of excessive and 
prolonged contractions, or in consequence of compression of the uterine 
wall between the presenting part and the bony pelvis. 

Symptoms. In perhaps the majority of cases of threatening rupture 
of the uterus there will be noticed certain vague premonitory symptoms, 
not, however, in themselves sufficiently characteristic to arouse suspicion 
of the impending danger. There are excessive crampy pains through 
the lower part of the abdomen, not ceasing with the cessation of the 
uterine contractions, and due to overdistention or compression of the 
uterine wall. It is but reasonable to assume that when rupture is immi- 



492 PATHOLOGY OF LABOR. 

nt'iit the distress occasioned by undue stretching of the uterine walls 

will be greater and more persistent than in normal labor. Most signifi- 
cant of impending rupture is an abnormally high position of the retrac- 
tion ring, fell at or near the line of the umbilicus. 

The occurrence of rupture of the uterus is made manifest by the fol- 
lowing usually characteristic phenomena: In course of some obstetric 
manipulation, or perhaps during a violent expulsive effort, the patient is 
suddenly seized with intense pain, differing entirely from a normal labor 
pain; this acute and cramp-like pain may he accompanied with a sound 
of tearing, audible in some cases to the bystanders, as well as to the 
patient. The uterine contractions invariably cease, the patient complains 
of a dull continuous pain in the lower part of the abdomen, and the 
evidence of profound shock is quickly manifest. The face is pale, 
exhibits the greatest suffering and apprehension, and becomes covered 
with a cold, clammy sweat; the respirations are rapid and shallow; the 
pulse small and imperceptible. Nausea, vomiting, and syncope fre- 
quently ensue. There is usually, but not always, an escape of blood 
from the vagina. A physical examination reveals a change in the eon- 
tour of the abdomen, and marked tenderness at the seat of rupture. If 
the rent in the uterus is large enough to permit the escape of the foetus 
into the peritoneal cavity, the foetal parts can be palpated through the 
abdominal wall, and apart from them may be felt the uterus, perhaps 
contracted down to the size of a foetal head. Upon vaginal examina- 
tion, the presenting part will be found to have receded, or, possibly, some 
other portion of the child maybe encountered, or a loop of intestine may 
be found prolapsed. If one or two fingers or the entire hand are intro- 
duced into the uterus, the site of the rupture can easily be detected, and 
the diagnosis confirmed. Some writers have called attention to the em- 
physematous condition of the abdominal walls arising from the entrance 
of air into the cellular tissue, and to a hypogastric tumor formed by the 
escaped blood. 

While the characteristic symptoms of rupture are usually present, cases 
have occurred in which neither shock, external hemorrhage, cessation 
of the uterine contractions, nor marked local pain was present, and in 
which the true condition was determined only at the autopsy. In this 
connection the following statistics from Jolly are of interest : Among 
580 cases of rupture the contractions ceased in 256 ; there was external 
hemorrhage in 148, collapse in 179, retraction of the presenting part in 
146, and abdominal pain in 133. The foetal limbs could be felt through 
the abdominal Avail in 77 cases. 

The practitioner will do well to view with suspicion any abnormal 
pain occurring during the second stage of labor, especially if accom- 
panied with shock. 

Prognosis. As before stated, rupture of the uterus is probably the 
most formidable complication of labor; the prognosis is exceedingly 
grave. The outcome for the child is almost necessarily fatal, 92 per 
cent, of all cases resulting in the death of the foetus. The immediate 
cause of death is asphyxia. The maternal mortality is not so high: 
probably under the best modern treatment about 60 per cent, of the 
women perish. Yet unrelieved the mortality is not less than 90 to 95 
per cent. 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 493 

The death of tho mother may result from shock, from primary or 
secondary hemorrhage, or from sepsis. More than one-half of the deaths 
occur within the first forty-eight hours after the injury. In pre-anti- 
septic days the outlook was still more gloomy, but with the increasing 
knowledge of abdominal surgery, and the better operative technique of 
the present day, the results have much improved. The following statis- 
tics from Schultze show the percentage of recoveries under different 
methods of treatment : 

Complete rupture without treatment, 20.2 per cent. 

Complete rupture treated with drainage, 36 per cent. 

Complete rupture treated by laparotomy, 44.7 per cent. 

As will be seen, the best results are obtained from the employment of 
surgical measures, and the prognosis is in some measure dependent on 
the promptness with which resort is had to operative interference. 

Treatment. Essential to the prophylaxis of uterine rupture is prompt 
recognition of conditions which may act as predisposing causes. In the 
presence of vigorous uterine contractions with no progress, excessive thin- 
ning of the lower uterine segment is to be suspected and examined for. 
When BandFs ring is felt more than half-way from the pubes to the 
umbilicus, labor should be ended as speedily as possible. The procedure 
to be adopted will depend upon the conditions present. In all cases an 
anaesthetic, and preferably chloroform, should be administered to the full 
surgical degree, to secure complete relaxation of the uterus. The uterus 
must be emptied promptly and with the least possible violence. In 
transverse presentation version is scarcely permissible, and decapitation 
will generally be required. In head presentation, if the child is living 
and the head has already engaged, the cautious use of forceps should be 
tried; but if difficulty be experienced in applying the blades the attempt 
should be abandoned. Two methods of procedure are then left to the 
obstetrician — Csesarean section or craniotomy on the living child. It 
is needless to say that the latter alternative should be adopted only as a 
last resort. 

When the proof of the child's death is conclusive, embryotomy is 
clearly indicated. Version should never be attempted in head presenta- 
tion, for no matter how skilfully the operation be performed, undue 
strain is put upon the uterine walls. The operation of election in these 
cases should be cceliotomy. 

After rupture has occurred the indications are to extract the child and 
placenta as soon as possible, to control the hemorrhage, and repair the 
laceration if practicable. If the child lies wholly, or for the most part, 
within the uterine cavity, delivery should be accomplished through the 
natural passages. In head presentation the forceps should be employed, 
care being taken by means of counter-pressure above the pubes that the 
child does not recede during the application of the instrument. In 
shoulder presentations opinions differ as to the best method of delivery. 
Davis condemns version as being liable to increase the already existing 
rupture. McLean cites a case of partial rupture with recovery of the 
woman, in which he performed podalic version, when all of the child 
except the head and one arm had escaped from the uterine cavity. In 
this case, however, the membranes were unruptured. Probably version 
performed with great caution is the best alternative. 



494 PATH0L001 OF LABOR. 

When the child is dead, embryotomy and prompt extraction are indi- 
cated. 

The placenta should be removed either by Credo's method of expres- 
sion or by manual extraction, and the uterus he emptied of blood-clots. 
Usually the uterus contracts promptly, and the hemorrhage for the most 

part ceases. The further treatment of the ease will depend entirely upon 
circumstances. 

In favorable conditions, the operator being well trained in abdominal 
surgery, the best results will be obtained by opening the abdomen, cleans- 
ing the peritoneal cavity of blood-clots, liquor amnii, and meconium, and 
closing the tear in the uterine wall with two or three rows of sutures, as 
in Csesarean section. Owing, however, to the ragged character of the 
wound, union frequently fails, especially if the laceration be extensive. 
In the latter event a supravaginal amputation of the uterus offers the best 
prospect for recovery. If an operation be decided upon, it will be wiser 
in the majority of cases to wait, after the patient is delivered, for a few 
hours, till she has reacted somewhat from the shock of the accident. 
In the mean time she should be stimulated by hypodermic injections of 
strychnine, digitalis and brandy, hot applications to the body, and other 
restorative measures. 

If, from the nature of the case, an operation is impracticable, the 
vagina should be thoroughly irrigated with a mild antiseptic solution, 
and a drain in the form of a roll of iodoform gauze introduced into the 
rent in the uterus, and allowed to protrude from the uterus into the 
vagina. The gauze is to be removed in twenty-four hours. 

When it is possible to make the diagnosis of incomplete rupture, the 
peritoneal cavity not having been opened, the treatment just described 
will be all that is necessary. The diagnosis of incomplete rupture is 
always more or less speculative, and, as already stated, the most rational 
method of treatment, when doubt exists, is an explorative cceliotomy. 

AVhen the child has escaped entirely, or for the most part, into the 
abdominal cavity, the indications are absolute for an abdominal section. 
The abdomen should be opened in the median line, and the child and 
placenta removed. The uterus should be emptied of blood-clots and the 
wound closed after the method employed in Csesarean section. The peri- 
toneal cavity should now be thoroughly cleansed of blood, liquor amnii, 
and meconium by repeated dry spongings, a drain left in the low T er angle 
of the wound or passed down through the posterior vaginal fornix, 
and the abdomen closed. Extensive and complicated tears are best 
treated by supravaginal amputation of the uterus. 



Rupture of the Symphysis Pubis. 

Swelling and softening of the ligameuts and cartilages of the pelvic 
joints occur in slight degree during pregnancy, especially at the sym- 
physis pubis. This softening is usually so slight as to give rise to little 
or no appreciable separation; exceptionally it is sufficient to result in 
perceptible mobility of the pubic bones upon each other. According to 
Stoltz, the separation may result from excessive softening of the joint 
structures or from direct violence during operative efforts at delivery. In 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 495 

the former instance the condition is known as relaxation of the joint, and 
the latter, occurring during labor, as rupture of the joint. Rupture prob- 
ably may occur in the absence of excessive relaxation. 

Causes. The predisposing causes of this accident are osteomalacia, 
rachitis, syphilis, and tuberculosis. Any profound cachexia may favor 
pelvic contraction. Unusually large foetal head or faulty presentation 
predisposes to rupture of pelvic articulations. Spontaneous rupture of 
the symphysis is rarely possible. In the great majority of instances the 
rupture is due to forceps. Excessive or misdirected traction is most 
frequently responsible for the injury. Of twenty-three cases of rupture 
of the symphysis collected by Havajewicz forceps had been used in 
eighteen. 

Diagnosis. When rupture of the symphysis occurs during labor the 
patient usually experiences a sharp pain in the joint. There may be a 
sensation of tearing. A sudden advance of the presenting part usually 
attends the rupture. In some instances the separation is accompanied 
by a crackling sound perceptible to the attendants, but it is not always 
present, nor is it pathognomonic, as the same sound may be produced by 
the cranial bones gliding over one another or over a prominence of the 
pelvis. In very rare cases the patient may be unaware of the injury of 
the symphysis until some time after the accident, when she attempts to 
walk. Simultaneously with extreme separation of the pubic bones there 
usually occurs some degree of injury to one or both of the sacro-iliac artic- 
ulations. 

The diagnosis is made by direct examination. With the index-finger 
introduced within the vagina behind the symphysis, and the thumb in 
front, the separation and mobility of the bones can readily be made out. 
The looseness of the joints is best detected by alternately flexing and 
extending one thigh, and by rotating it outward, while the other is firmly 
held by an assistant. 

The Prognosis may be grave if the vagina or bladder is torn. It is 
extremely so if the peritoneum is invaded by the laceration. In neglected 
cases permanent mobility of the joint may remain, with partial or com- 
plete inability to walk. 

Treatment. The treatment of rupture or relaxation of the symphysis 
when discovered at the time of the injury consists in immobilizing the 
joint for from four to six weeks by means of a firm pelvic bandage. The 
patient in the mean time must be kept in bed. The hammock bed of 
Quierel or of Ayres, as employed in the after-treatment of symphyse- 
otomy, may be utilized. Laceration of the soft parts should be repaired 
by immediate suture. Neglected cases may be successfully treated by 
vivifying the articular surfaces with a suitable instrument passed sub- 
cutaneously, and immobilizing the joint with a firm spica bandage, with 
rest in bed for a month or more. Wiring the bones together is not 
necessary, and yields no better result. 

Thrombosis of Vagina and Vulva. 

Thrombosis is a term used in this connection to designate an extrava- 
sation of blood into the cellular tissue of the vagina and vulva. The 
hemorrhage may be venous or arterial, but usually the former. The 



496 PATHOLOGY OF LABOH. 

accident is rare* Winoke] estimates the frequency at one in 1600 labors, 
and Charpentier one in 2000. These estimates do not include oases of 
comparatively frequent occurrence in which there may be a slight capil- 
lary oozing, due to a varicose condition of the superficial veins of the 
vulva. 'The Bwelling is most commonly observed at one side of the 
vulva; when within the vagina it is located either upon the posterior or 

the lateral aspect. Labarie has shown that the site of tumor formation 
18 dependent upon the anatomical structure of the part affected. When 
the hemorrhage occurs beneath the skin of the perineal region the extra- 
vasations may extend down the thighs or upward on the abdomen; when 
below the superficial fascia it remains localized. Extravasations which 
occur beneath the deep fascia of the perineum may extend into either 
iliac fossa. When the blood is effused between the deep fascia and the 
peritoneum, a hematoma may form in the abdomen, extending as high 
as the umbilicus. When either lateral or posterior wall of the vagina 
is the seat of the extravasation, it is limited in extent by the dense fibrous 
layer surrounding this structure, and remains localized. 

Etiology. The principal predisposing cause of thrombosis of the vulva or 
vagina is the obstruction to the local circulation, occasioned by advanced 
pregnancy. Other predisposing causes are deformity of the pelvis, dis- 
proportion between the foetus and the birth-canal, circulatory disease or 
morbid alteration in the composition of the blood. Among the exciting 
causes may be mentioned anything which increases the pressure in the 
already greatly distended veins. 

The most common exciting causes are blows, falls, or violent concus- 
sion, the unskilful use of the forceps, awkward attempts at version, and 
unusual size of the foetus. Sometimes the accident is spontaneous. 

Symptoms. There may be vague premonitory symptoms, such as pain 
of a sharp lancinating character, extending from the vulva down the 
thighs or through the pelvis. Usually, however, the first thing to attract 
attention is a swelling either at one side of the vulva or within the vagina. 
The tumor appears most frequently during the severe pains of the second 
stage of labor, and usually develops rapidly, though it may be from 
twelve to twenty-four hours before it attains its maximum. Upon 
examination there will be found a tumor, smooth, circumscribed when 
small, but diffuse when very extensive, and imparting to the finger an 
elastic feel. Fluctuation may or may not be present, according as the 
extravasation is a true hematoma with a limiting wall or a simple, iufil- 
tration of the tissues. It is generally of a dark, livid color, and the 
ecchymosis may involve ultimately a large area in the vicinity of the 
tumor. If the formation of the thrombus occurs before the delivery of 
the child, it may obstruct the birth. When the tumor develops at the 
close of the second, stage of labor, its presence may interfere with the 
expulsion of the placenta, or, later, with the lochial discharge. If the 
thrombus be of any considerable size, the symptoms of internal hemor- 
rhage are present, namely, feeble, rapid pulse, pallor, cold clammy sweat, 
dimness of vision, shallow respiration, etc. Finally, if the tumor rup- 
tures, external hemorrhage of greater or less degree is added to the fore- 
going symptoms. 

Termination and Prognosis. A thrombosis in this situation may termi- 
nate as do hasmatomata in other localities: it may undergo resolution and 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 497 

be absorbed; it may become encysted and undergo fatty or calcareous 
degeneration; it may rupture subsequently, or become infected and sup- 
purate. Suppuration is more likely to follow a spontaneous rupture than 
an open incision. The prognosis is generally good under proper treat- 
ment. The outlook is more favorable when the tumor appears after 
delivery. The dangers to which the woman is exposed are hemorrhage, 
sepsis, and those of instrumental or manual delivery. 

Treatment. The prophylactic treatment when any undue congestion 
of the venous circulation is evident, or when small extravasations occur 
during the last few weeks of pregnancy, consists in keeping the patient 
in the horizontal position for the most of the time. 

The active treatment will vary according to the size of the thrombus, 
the amount of pressure it exerts, and the time of its appearance. When 
the tumor appears before delivery, and by its size renders the passage of 
the child's head impossible without spontaneous rupture, an anaesthetic 
should be administered, the tumor laid widely open, all clots turned out, 
the cavity irrigated with a weak antiseptic solution or with sterilized 
water, and the hemorrhage controlled by packing snugly with iodoform 
gauze. The subsequent treatment will consist in daily irrigations and 
repacking the wound with gauze, allowing the cavity to heal from the 
bottom by granulation. If the thrombus does not appear until after 
delivery, it is better treated by compression with a view to promoting 
absorption. The case should, however, be carefully watched, and, if 
spontaneous rupture threatens, the tumor should be opened and treated 
as detailed above. Care will be needed to prevent infection, since a large 
open wound is left after operation. 



32 



CHAPTEE XXII. 

THE HEMORRHAGES. 

Hemorrhage from Partial Separation of an Abnormally Situated 
Placenta — Placenta Praevia. 

Normally the implantation of the placenta is wholly within the 
upper uterine segment, and its attachment remains undisturbed till the 
foetus is expelled. When its site encroaches upon that portion of the 
uterus which undergoes dilatation in the first stage of labor, the placenta 
is of necessity partially detached at the onset of labor or in course of the 
partial expansion of the lower uterine segment, which takes place during 
the later weeks of gestation, and hemorrhage follows from the torn blood- 
vessels. To this abnormal situation of the placenta is given the name 
Placenta Prosvia, since the placenta lies partly in advance of the 
foetus. To the form of hemorrhage occurring from prsevial placenta, 
Rigby applied the term unavoidable hemorrhage, in distinction from that 
proceeding from partial detachment of the normally situated placenta, and 
which he called accidental hemorrhage. 

Varieties. Three or four varieties are usually described : Lateral, in 
which the placenta extends into the lower uterine segment, but not to the 
internal os; marginal, in which it barely reaches the internal os; 'partial, 
in which it partly overlaps the fully dilated os, and complete, in which it 
wholly covers the fully dilated os. The term central placenta praevia is 
sometimes employed to designate a central implantation upon the lower 
uterine segment. But these terms are not all accurately descriptive, and 
the multiplication of varieties is needlessly confusing. It is sufficient to 
make two classes of cases : partial and complete placenta prsevia. 

The Source of the Hemorrhage is the uncovered portion of the placental 
site, sometimes the placenta as well. Hofmeier has shown that the lower 
uterine segment is supplied by a branch of the uterine artery which 
descends from the upper segment. The arrest of hemorrhage from the 
lower portion of the uterus after labor is largely due to the retraction of 
the contractile upper segment, diminishing the blood-supply to the lower. 

Before the expulsion of the foetus, retraction being incomplete or 
absent, there is a free exchange of blood between the active and the 
passive segments; hence the hemorrhage from the bared portion of the 
obstetric cervix in placenta praevia. A placental cotyledon may bleed 
while partially detached, but after complete separation its vessels are 
obliterated by coagula. 

Frequency. The frequency of prsevial insertion of the placenta is 
usually stated at about 1 in 1000 cases. This estimate corresponds very 
nearly with the results of Midler's investigation, who found 813 cases 
reported in 876,432 labors, and with the average statistics afforded by 
lying-in hospitals. The frequency is several times greater in multipara 
than in women pregnant for the first time. 
(498 ) 



THE HEMORRHAGES. 499 

Structural Anomalies. Owing to the comparative thinness of the decidua 
in the region of the os internum the prsevial portion is less perfectly 
developed than other parts of the placenta. This gives rise to uneven- 
ness in thickness and to irregularity of form. Sometimes the placenta 
presents a horseshoe shape. There may be isolated cotyledons which are 
almost completely separate from the main structure. 

The thinned portion of the placenta has a comparatively insecure 
attachment, a fact which increases the tendency to hemorrhage. The 
rest of the organ is often abnormally adherent. Miiller found adhesion 
in 54 out of 142 cases of placenta prsevia. The insertion of the cord is 
usually eccentric. 

Etiology. The causes of placenta prsevia are not definitely known. 
Probable causes are conditions leading to tardy fixation of the ovum, 
permitting it to fall to the lower uterine segment. Atrophy of the 
decidua, relaxation and subinvolution of the uterus, chronic endome- 
tritis, new growths and malformations of the uterus are, accordingly, 
believed to be factors in the etiology. Consistently with this hypothesis 
low implantation of the placenta is most frequently met with in women 
who have borne several children. 

Miiller finds the cause in arrested abortion. The ovum, he thinks, 
may be partially separated and displaced by uterine contractions, and find 
secondary attachment lower down. 

Osiander suggests that the influence of gravity should be taken into 
account in explaining low fixation. 

Recently Hofmeier and Kaltenbach have proposed the theory that the 
anomaly may originate from the development of the placenta over the 
decidua reflexa of the lower pole of the ovum. Their views have not, 
however, met with general acceptance. 

Hart maintains that the vicious insertion is primary. He believes 
that the human ovum can become engrafted only on a surface denuded 
of epithelium, and that the ovum may exceptionally meet with such a 
surface only in the lower uterine segment. Kaltenbach 7 s objection that 
the ovum could not find lodgement near the cervix, but would rather 
escape through it and be lost, he thinks, does not hold, since the os inter- 
num is practically obliterated by folds of the hypertrophied decidua. 
Ingleby found a low insertion of the Fallopian tubes in two remarkable 
cases, in each of which placenta previa had occurred in several successive 
pregnancies. 

Symptoms. Usually there are no symptoms in the earlier months of 
pregnancy. The first indication is generally a sudden hemorrhage of 
greater or less severity. This may occur at any period of gestation. 
The liability to hemorrhage increases with each succeeding month of 
pregnancy. Much bleeding from this cause is rare before the seventh 
month; in the vast majority of instances the first attack is observed in 
the eighth or ninth. It comes on with no premonition, and generally 
without obvious cause. Exceptionally the paroxysm follows some 
unusual muscular exertion. The amount of blood-loss varies with the 
conditions of the individual case. It is proportionate to the extent of 
placental separation. It is greater the more nearly the prsevial attach- 
ment is complete and the nearer to term the hemorrhage. From one to 
three pints of blood may be lost in the first attack in pregnancy, and 



500 PATHOLOGY OF LABOR. 

this quantity may be greatly exceeded daring labor. Characteristic of 
thi- form oi hemorrhage is the fact that the flooding is most profuse in 
the intervals between the pains. Daring the pains the blood-supply to 
the torn vessels IS almost wholly interrupted by the contraction of the 
apper uterine segment. The first hemorrhage, especially if it occurs 
during labor, may go on to a fatal termination, or it may cease to be 
renewed at any day or hour on further separation of the placenta. But 
it is not alone the copious outpour of blood that is dangerous. In a 
certain proportion of cases the bleeding is slight but persistent, and if 
neglected, though at no time large in amount, it may ultimately place 
the patient's life in grave peril. To the clinical picture are frequently 
added the signs of acute anaemia; these are : pallor, perspiration, skin 
cold and clammy, respiration irregular, sighing, sobbing, yawning, pulse 
rapid, thready, compressible; thirst, jactitation, tinnitus aurium, air- 
hunger, nausea, dimness of vision, and syncope. 

Diagnosis. Hemorrhage during pregnancy, and especially in the later 
months, demands immediate investigation to ascertain its cause. This 
form of hemorrhage must be distinguished from so-called " accidental 
hemorrhage. " The diagnosis must rest on the physical signs. 

Abdominal Signs. Frequently the location of the placenta, when the 
implantation is partly on the anterior wall of the uterus, can be made out 
by palpation over the abdomen. Sometimes the edge of the placenta 
presents a resisting ring perceptible by the abdominal touch. Within 
the placental area the foetal parts are felt indistinctly, owing to the inter- 
position of the placenta between the foetus and the examining fingers, 
while elsewhere they are more readily made out. In placenta previa 
ballottement is wanting or difficult, as is also the recognition of the foetal 
parts by the vaginal touch. The only pathognomonic sign of placenta 
praevia is the recognition of the abnormal situation of the placenta by 
the examining finger passed within the os. If labor has begun the os 
will be found soft and patulous, and upon introducing the finger through 
the cervix the placenta may be identified by its characteristic stringy feel. 
To distinguish a complete from an incomplete placenta praevia, the finger 
is passed well up on both sides of the cervix, feeling for the margin of 
the placenta: if the fully dilated os is entirely surrounded by placental 
tissue, the placenta praevia is complete; if the finger can be introduced 
between the margin of the placenta and the wall of the cervix, there is 
present an incomplete placenta praevia. 

Prognosis. Placenta praevia is a dangerous complication of pregnancy 
and labor for both mother and child. Much depends, however, on the 
degree to which the placenta is praevia, and in general the mortality is 
capable of great reduction under proper treatment. Churchill and Read 
place the maternal death-rate at from 25 to 33 per cent. In 67 cases 
recorded by Barnes, 8.8 per cent, of the mothers were lost. Midler's esti- 
mate of the mortality is 23 per cent, for the mothers and 64 per cent, for 
the children. In 61 cases Murphy had but 2 maternal deaths. Winckel 
thinks that not more than 5 or 10 per cent, of the mothers should be 
lost. In 739 collected cases there were 57 maternal deaths in incomplete, 
and 109 in complete placenta praevia. It is the writer's conviction that 
under modern methods of treatment the maternal mortality should not 
exceed the limit stated by Winckel, and the foetal should not be more 



THE HEMORRHAGES. 501 

than 50 per cent. The risks to which the mother is exposed are not only 
those of the primary hemorrhage, but also those of operative interfer- 
ence and of the sequelae. Malpresentations and malpositions of the 
foetus are more frequent in placenta prsevia than in normal placental 
implantation, and there is greater risk of infection during labor, of post- 
partum hemorrhage, and of thrombotic affections. 

Treatment. The chief element of danger in placenta prsevia is hemor- 
rhage, and the control of hemorrhage is, therefore, the principal indica- 
tion in the treatment. Here, as in general, while the child's life must 
not be undervalued, the interests of the mother are paramount. It will 
be convenient to consider the management of placenta praavia under the 
following heads : 

(1) Before the Fcetus is Viable. The death of the mother, by 
reason of vicious insertion of the placenta, is extremely rare before the 
end of the seventh month of gestation. A partially expectant plan of 
treatment is usually permissible till the viable period is reached, in the 
hope of saving the child. This course is the more justifiable in hospital 
practice, where the woman can be kept under close observation, and 
measures for the control of hemorrhage can be promptly enforced should 
the occasion arise. Quiet, and if need be, rest in bed must be enjoined. 
The avoidance of much muscular exertion and of the causes of pelvic 
congestion, including coitus, is imperative. Vaginal douches of hot 
water and vinegar, as advised by Winckel, are of doubtful utility. 
They are liable to defeat their own object by provoking uterine contrac- 
tions. 

If the fcetus is dead the uterus should immediately be emptied. The 
latter treatment usually applies, too, if the hemorrhage is profuse or 
persistent. 

(2) After the Fcetus is Viable. Nearly all the fatal termina- 
tions in placenta prsevia occur after the eighth month of pregnancy. 
The development of the utero-placental circulation increases with each 
succeeding month, and the danger is greater the nearer the case is to 
term. In the later weeks of gestation the woman is liable to be seized at 
any moment with hemorrhage, which may go on to a fatal extent before 
medical aid can reach her. In all except simple marginal placenta pnevia, 
with little or no hemorrhage, the pregnancy should be terminated imme- 
diately the period of full foetal viability is reached, if the condition has 
been discovered. Moreover, it is imperative that the physician remain 
with the patient till labor is complete. 

If the development of the foetus has passed the seventh month its 
chances for survival are fully as good by premature evacuation of the 
uterus as by waiting till repeated hemorrhages have occurred, since, after 
much bleeding from the uterus, the danger from asphyxia is exceedingly 
great. 

Management of Labor. The induction of labor is conducted in accord- 
ance with the usual rules. Krause's method — passing one or two bougies 
between the membranes and the uterine wall — may be elected when time 
permits. A water-bag may also be placed in the cervix for the double 
purpose of preventing hemorrhage and of provoking uterine contrac- 
tions. When more rapid delivery is indicated, the cervix should be 
dilated by the use of the water-bag till the os internum is effaced. The 



602 PATHOLOGY OF LABOR. 

dilatation may then be completed by the manual method. A firm abdom- 
inal binder is applied a- a safeguard against the accumulation of blood 
in the uterus. Measure- for controlling hemorrhage during labor are 
the following: 

Rupture op the Membranes in Partial Detachment <>f the 

PLACENTA, In mere marginal placenta previa the hemorrhage may 
frequently he controlled by rupturing the membranes, and, if necessary, 
Stimulating the uterus to contract. On escape of the waters the foetus 
is driven down by the uterine contractions and the bleeding is partially 
or wholly arrested by the pressure of the presenting part. An abdom- 
inal bandage is a valuable aid for maintaining this pressure. This pro- 
cedure usually suffices in the class of cases referred to, and it has the 
advantage of simplicity. The progress of dilatation is somewhat retarded, 
but that is a matter of minor importance in comparison with the effects 
of much blood loss. The method is suited, however, only to cases in 
which the lower margin of the placenta lies well above the os internum. 
It is positively contraindicatcd in conditions which may necessitate ver- 
sion. In addition to the perforation of the bag of waters the presenting 
edge of the placenta should be separated from the lower uterine segment. 
The finger is passed through the cervix and the placental margin peeled up 
as far as the finger can easily reach. This favors retraction of the lower 
uterine segment and the ligation of the torn vessels. Should the bleed- 
ing still continue a water-bag may be introduced, or when the dilatation 
is sufficient the forceps may be applied, if the vertex presents, and gentle 
traction be made to hold the head in the lower uterine segment. If the 
breech presents, one or both feet should be brought down as soon as the 
dilatation permits. 

Vaginal Tamponade. The vaginal tamponade is a valuable measure 
in cases in which there is hemorrhage with little or no dilatation of the 
cervix. The vaginal tampon, if it is properly applied and the uterus 
is supported by an abdominal binder, effectually controls the bleeding. 
The method of procedure is as follows : The bladder and the rectum 
should be empty. The material for the tampon may be absorbent cotton 
or strip gauze, either plain or impregnated with iodoform or with oxide 
of zinc. The gauze has the advantage that it can easily be removed. 
The strip may be three or four inches in width. Whatever the material, 
it should be wet in order to pack firmly. If the vagina is healthy and 
has not been infected by previous manipulations, no internal cleansing is 
necessary. In all other respects the usual antiseptic precautions must be 
observed. The material used for the vaginal tamponade must be aseptic. 
It is not necessary that it be antiseptic. No harm will be done, however, 
by impregnating it with some feebly toxic antiseptic. Mercurials are 
especially unsuitable for the purpose, owing to the danger of mercurial 
intoxication. If absorbent cotton is to be used for the tampon, twenty 
or thirty pledgets of the size of an English walnut should be in readi- 
ness. The patient is placed in Sims' s position; a Sims' s speculum is 
introduced and held by an assistant. A convenient forceps for carrying 
the cotton balls is a straight Keith. The first pledget is placed behind 
the cervix, the next in front of the cervix, then one at each side. The 
intervening spaces are filled, and a second layer packed on the first. This 
is continued until the vagina is filled to the vulva. A pad of absorbent 



THE HEMORRHAGES. 



503 



cotton is placed over the external genitals, and over this a firmly applied 
T bandage, which holds the tampons securely in place. If gauze is used 
it is packed in similar manner. The vaginal tampon is removed in eight 
to twelve hours, by which time the labor will in most cases have pro- 
gressed sufficiently to be managed by other means. Should there still 
be bleeding, and the dilatation not have progressed far enough to efface 
the os internum, the packing may be renewed. 

Cervical Tamponade. Equally efficient for the control of bleeding 
in placenta praevia during the beginning dilatation of the cervix is the 

Fig. 334. 




Barnes's dilating water-bags. 



complete occlusion of the cervical canal. This is effected by means of 
an elastic bag, which is introduced within the cervix and distended till 
the canal is successfully plugged. Available for this purpose are the 
fiddle-shaped bags of Barnes and of McLean, that of Tarnier, and the 



Fig. 335. 




McLean 



Champetier de Ribes ballon. A tube is attached to the bag through which 
the latter may be filled. For introduction of the dilating bags the patient 
may lie in the lithotomy position, the cervix being held well forward 
toward the pubes by means of a volsella caught in the anterior lip. One 
or two fingers are introduced within the vagina and the instrument 
passed on these as a guide. A Sims position, however, is usually to be 
preferred. With the perineum retracted by means of a Sims speculum, 



504 PATHOLOGY OF LABOR. 

and the cervix drawn forward, the os externum la readily brought into 
view. The dilating bag is rolled snugly into a cylindrical shape, seized 

with a lun- forceps, and lodged in the cervix. The forceps is then with- 
drawn and the bag distended. As a precaution against infection, should 

the bag accidentally he ruptured, boiled water or a mild antiseptic solu- 
tion should he used for filling the bag. Air is unsuitable, owing to the 
risk of air embolism should the bag hurst. The water is injected with a 
Davidson or similar bulb-syringe provided with a nozzle which fits the 
tube. As a precaution against overdistention the operator should know 
by previous trial how many bulbfuls are required to expand the bag to 
its limit. A rigid asepsis must, of course, be observed. 

The cervical tampon has the double effect of controlling hemorrhage 
and at the same time promoting the dilatation of the cervix more effect- 
ually than does the vaginal packing. It has the advantage over the 
latter of causing less discomfort to the patient. When thought necessary 
both these measures may be employed. As a rule, they are to be replaced 
by other measures after the os internum is effaced. This is usually accom- 
plished in eight or ten hours. Yet, when time permits, the labor may be 
satisfactorily completed with the aid of the dilating water-bag. The 
Champetier de Ribes bag is especially to be recommended after the dila- 
tation of the cervix is well established. It is best introduced within the 
amniotic sac. 

Manual Dilatation. Manual dilatation, or the so-called accouche- 
ment force, which has recently been advocated by Fournier and other 
authorities for the treatment of placenta prsevia, is seldom permissible, 
except for completing the canalization of the utero-eervical zone after it 
is already well advanced. To a woman who has already sustained much 
blood-loss, forcible and rapid dilatation of the cervix ab initio is danger- 
ous, owing to the shock involved. A considerable hemorrhage must 
necessarily occur during the dilatation, and the fingers in the cervix 
afford a very imperfect means for controlling it. The danger, too, of 
uterine rupture and of infection is increased in low implantation of the 
placenta, and this is an objection to forcible dilatation of the cervix. 

Podalic Version. One of the most effectual measures for the con- 
trol of hemorrhage in placenta prsevia is podalic version, and no method 
has yielded better results. With one or both feet brought down the 
foetus serves as a conical plug, which is forced down or can be drawn 
down as fast as the dilatation progresses. The cervix is thus securely 
tamponed during the entire course of the birth. Lomer, of Berlin, 
reports a maternal mortality of 4 J per cent, in 101 cases treated by 
version. It must not be forgotten, however, that any kind of violent 
interference is unsafe when the woman has lost much blood. If, there- 
fore, much bleeding has occurred, version is to be undertaken only when 
little difficulty is likely to be encountered. In most cases it is a grave 
mistake to add the shock of immediate delivery to that of version. The 
excellent results of version in placenta prarvia have been obtained only 
when the operation has not been followed by immediate extraction. 
Either the external, the bipolar, or the internal method may be chosen, 
according to the conditions present. External version before labor is 
exceptionally possible. The bipolar method of Braxton Hicks has the 
advantage over internal version that it can be performed early in the 



THE HEMORRHAGES. 505 

labor, as soon as one or two fingers can be passed through the os uteri, 
and there is less danger of infection than when the whole hand is intro- 
duced. The fingers passed through the membranes, one or both feet are 
seized with the hand and brought down. When the placental margin 
cannot readily be reached, in emergency the placenta may be perforated. 
With the foetus inverted the hemorrhage is completely under control, 
and the delivery can usually safely be left to nature. Rarely it may be 
necessary to assist the birth, delivering very slowly. 

For the full technique of the different methods of version the reader 
is referred to the chapter on Obstetric Surgery. 

Other Methods. Partial Separation of the Placenta. Separation of 
the presenting portion of the placenta, as proposed by Barnes, often 
suffices in marginal implantation. It permits retraction of the zone 
uncovered. In most instances of this form of placenta prsevia no other 
treatment will be required. One or two fingers are passed between the 
placental edge and the uterine wall, and the margin of the placenta is 
peeled up by sweeping the fingers laterally. The detachment should be 
carried far enough to uncover completely the dilating zone of the uterus. 
An abdominal binder should be applied. 

Complete Separation of the Placenta, as advised by Simpson, is appli- 
cable in case the child is dead or not yet viable. 

Precautions. It must not be forgotten that the essential object of 
treatment in placenta praevia is the control of hemorrhage. Hemorrhage 
under control, there is no occasion, as a rule, for active interference. Vio- 
lent measures are especially contraindicated in the acute anaemia which 
often obtains in this class of cases at labor. Very little shock in such con- 
ditions will frequently precipitate a fatal issue. A large proportion of 
deaths in placenta prsevia is distinctly chargeable to over-zealous inter- 
ference. Owing to the low placental site and the intra-uterine manip- 
ulations usually required, the risk of sepsis is much greater than in 
ordinary labors. Precautions against sepsis must be rigidly observed. 
Post-partum hemorrhage is of frequent occurrence. The vessels of the 
placental site are not so successfully ligated after labor, when the implan- 
tation is on the lower and less contractile portion of the uterus, as in 
normal conditions. The amount of post-partum flow must always be 
watched. Retraction of the uterus should be promptly secured and 
rigidly maintained. Ergot should be given for two or three days after 
labor. 

Hemorrhage from Premature Separation of a Normally Situated 
Placenta; Accidental Hemorrhage. 

Hemorrhage may occur during labor or the later weeks of pregnancy, 
as the result of a premature, partial, or complete detachment of a nor- 
mally inserted placenta. To this form of bleeding Rigby, as already 
explained, applied the term accidental hemorrhage. 

Hemorrhage of this character is exceedingly rare, occurring once in 
8000 or 10,000 cases. Goodell, in 1870, had collected but 106 cases. 

Varieties. Two varieties of accidental hemorrhage are usually de- 
scribed : apparent, and concealed or internal hemorrhage. In the first 
variety the escaped blood finds its way between the membranes and the 



506 I'ATHOLOGY OF LABOll. 

decidoa, and escapes through the cervix, [n the second variety, the blood 
fails to find an outlet, and may collect in sufficient quantity within the 
uterus t»> occasion alarming symptoms or even death, with no visible 
bleeding. The former variety is the one most frequently met with. 

In the concealed form, according to Goodell, either of the following 
conditions may obtain: 1. The placenta may be detached at the centre, 
the margin still being adherent. 2. The placenta may be detached at 
one edge, the membranes being separated for a short distance beyond the 
placental margin. 3. The edge of the placenta and the adjacent portion 
of the membranes being detached, the latter may rupture, permitting 
escape of blood into the amniotic sac. 4. Detachment of the placenta 
may take place, accompanied with separation of the adjacent membranes, 
but the foetal head, acting as a ball valve, may prevent external escape 
of the blood. 

While the first attack of hemorrhage may occur after labor has com- 
menced, almost invariably it takes place during the last three months of 
pregnancy. 

Etiology. Probably the most common predisposing cause is to be 
found in a diseased condition of the decidua or in certain morbid states 
of the placenta itself. Tubercular and syphilitic degenerations of the 
lining of the uterus are recognized causes. Cases have been reported 
in which the placenta was found to be the seat of a beginning of fatty 
and calcareous degeneration. Nephritis, extreme anaemia, diabetes, and 
some of the acute infections diseases, as scarlatina, diphtheria, and variola, 
have been assigned as etiological factors. Certain anomalies of the foetal 
appendages, great distention of the uterus, and short cord may favor 
premature separation of the placenta; most cases occur in multiparas who 
have borne many children or whose general health is impaired. In the 
presence of any of the foregoing predisposing causes, it is easy to under- 
stand how an apparently trivial exciting cause may give rise to slight 
separation of the placenta from its attachment to the uterine wall. 
Thus, traumata, as a blow on the abdomen, a fall, or violent muscular 
exertion, etc., are generally given as exciting causes of accidental hem- 
orrhage. 

Diagnosis. Apparent Variety. The existence of hemorrhage is 
obvious. Rupture of the uterus and placenta prsevia must be excluded. 
The former occurs later in the labor than does accidental hemorrhage, 
and is characterized by recession of the presenting part, diminution of 
the uterine tumor and the development of a new abdominal tumor; 
placenta prrevia is readily differentiated by a physical examination. In 
accidental hemorrhage the uterine tumor is increased in size, and the 
flooding usually takes place before the rupture of the membranes. 

Concealed Variety. First to attract the attention usually are the 
systemic effects of hemorrhage. If the blood effusion is extensive, the 
fact is betrayed by pallor, anxious expression of countenance, cold 
extremities, feeble and rapid pulse, sighing respiration, collapse. The 
uterine contractions are weak, yet continuous uterine pain is sometimes 
present, owing to distention of the perimetrium. 

On abdominal examination, bulging of the uterine wall may be noted 
at the seat of the blood collection ; the uterine tumor presents a boggy 
feel, the foetal parts are indistinctly felt, and the foetal heart-sounds are 



THE HEMORRHAGES. 



507 



Fig. 336. 



feeble and irregular. The condition may sometimes be detected by 
pushing up the presenting part and allowing a portion of the blood and 
liquor amnii to escape. It should not be 
forgotten that concealed may coexist with 
an insignificant external hemorrhage. 

Concealed accidental hemorrhage might 
be confounded with ruptured tubal preg- 
nancy, but the latter is readily distin- 
guished by physical exploration and by its 
history. 

Prognosis. In apparent hemorrhage the 
prognosis is good for the mother, but is 
frequently fatal for the child. In the 
concealed variety the prognosis is grave. 
The maternal mortality is more than 50 
per cent., while the infant mortality is 
about 90 per cent. The high death-rate 
in case of the mother is due to extreme 
anaemia, sepsis, post-partum hemorrhage, 
and to shock and exhaustion from over- 
distention of the uterus. The foetal mor- 
tality arises chiefly from asphyxia, the 
result of interruption of the utero-placental 
circulation. Prematurity is sometimes a 
factor. 

Treatment. In the external variety of 
hemorrhage, if the bleeding is moderate 
in amount, the mother's condition being 
fairly good, and the foetus still viable, 
the only treatment demanded is rest in ^ h ° died of accidental hemorrhage at 

bed, a full dose of Opium, and absolute ^Matemite de Beaujon. (PiNARoand 

quiet for a week or ten days. Even a 

moderately free hemorrhage may sometimes be arrested by these means. 

In either variety, when the blood-loss is alarming, the uterus must be 
emptied. If the os is partially dilated, the membranes should at once be 
ruptured. If the os is small and rigid, the vaginal tampon, or, better, 
a Barnes cervical dilator may be employed. This temporarily arrests 
the bleeding and at the same time dilates the cervix. While the use of 
the vaginal or the cervical tampon is open to the objection that it may 
convert an external into a concealed hemorrhage, this is scarcely possible 
if the uterus is firmly supported with a tight abdominal bandage. After 
the membranes have ruptured the tampon is contraindicated. When 
immediate delivery is demanded the cervix should be incised. 

If the condition of the mother permits, it is usually advisable to wait 
till the os is partially dilated before rupturing the membranes, as then ver- 
sion by Hicks' s bipolar method may more easily be performed. Goodell, 
however, advises early rupture of the membranes, immediately followed 
by the application of a very tight abdominal binder over a pad placed 
above the fundus of the uterus, together with the free administration of 
ergot. Labor should be terminated as speedily as possible by manual 
dilatation and version, or the forceps. 




Frozen section of the uterus of a woman 



PATHOLOGY OF LABoil. 

It' the patient's condition is such as to forbid active obstetric inter- 
ference, Bne should be freely stimulated, the foot of the bed should be 

elevated, and means taken to replace the blood lost by hemorrhage before 
Subjecting her to the additional shock of version. The relaxed uterus 
should be made to contract by means of friction or compression of the 
fundus, a linn abdominal compress, and the administration of small 
doses of ergot. 

It* the child has perished, craniotomy is advisable if the oh be not 
fully dilated. Csesarean section, as advised by some authorities, can 
seldom be justifiable. 

The after-treatment consists in measures intended to promote uterine 
contraction and in the treatment of acute anaemia. The woman is espe- 
cially liable to post-partum hemorrhage. The treatment, both prophy- 
lactic and remedial, is the same as in post-partal hemorrhage under other 
conditions. 

The shock and collapse of anaemia are to be combated with strych- 
nine, alcoholic stimulants, and by submammary or intravenous injections 
of the normal salt solution. Elevating the foot of the bed and auto- 
transfusion, by bandaging the extremities, are useful expedients. 

Post-Partum Hemorrhage. 

There is no emergency in obstetric practice that so seriously jeopardizes 
the patient's life, that calls for so prompt and sure treatment for its relief, 
and in which all the courage and skill of the obstetrician are so suddenly 
put to the test, as in a severe case of post-partum hemorrhage. Before 
entering the lying-in chamber to assume charge of a confinement case, 
the physician is in duty bound to have at his fingers' ends the measures 
necessary to meet promptly this formidable emergency. There is no 
time for hesitation, nor to send for a consultant, as a few moments may 
suffice to turn the scale either for or against the patient's chances of 
recovery. Fortunately for the patient, as well as for the medical attend- 
ant in the vast majority of cases, this is a preventable accident; and 
many physicians of large obstetrical practice may pass a lifetime without 
having encountered a fatal case of post-partum hemorrhage. 

Spiegelberg even goes so far as to say that severe post-partum hemor- 
rhage is almost without exception the fault of the medical attendant. 
The fact cannot be too strongly impressed upon the student's mind, that 
if the third stage of labor be conducted properly and as though hemor- 
rhage were impending, the number of severe cases of post-partum hem- 
orrhage would be much diminished. 

Etymologically, the term post-partum hemorrhage applies to a hemor- 
rhage arising at any time after the birth of the child and from whatever 
cause. The term has, however, in its technical sense, come to be 
restricted to hemorrhage from the uterine cavity occurring during 
the first few hours after the child is delivered; in the great majority 
of instances, it takes place before or immediately after the placenta is 
expelled. 

The term " secondary post-partum hemorrhage," or puerperal hemor- 
rhage, is applied to flooding wdiioh occurs after the first six hours of the 
puerperium. 



THE HEMORRHAGES. 509 

Hemorrhage from rupture or inversion of the uterus, malignant or 
benign growths of that organ, or from lacerations of the cervix or 
vagina, are not included under post-partum hemorrhage in the technical 
sense of the term. 

Frequency. Regarding the accident as preventable, it follows that the 
records of hospitals and large lying-in institutions, from which the greatest 
proportion of statistics is gathered, and in which the labors are conducted 
presumably by men of special skill, naturally show a smaller percentage 
of cases of post-partum hemorrhages than are observed in private practice. 
In corroboration of this statement we note that Playfair considers post- 
partum hemorrhage one of the commonest complications with which the 
obstetrician has to deal; he would not, however, imply that fatal or even 
alarming hemorrhages are thus common. On the other hand, the records 
of Guy's Hospital furnish but one case of dangerous post-partum hemor- 
rhage in 2040 labors; St. Thomas's Hospital reports give one in 2172 
labors; Veit, from the statistics of a number of Continental authorities, 
was able to collect only five fatal cases in 47,765 deliveries. This latter 
statement certainly underestimates the death-rate from this source. In 
general, it may be stated that mild cases of post-partum hemorrhage 
occur once in 100 labors; severe cases, once in from 1000 to 1200; and 
fatal cases once in from 4000 to 6000 labors. 

Etiology. First. The principal cause of post-partum hemorrhage is 
uterine inertia or atony of the uterine muscle. Normally, with the sepa- 
ration of the placenta there is a certain amount of blood-loss, which, 
however, is quickly controlled by the firm contraction of the uterus; the 
gaping ends of the enlarged uterine sinuses are closed by the contraction 
of the network of muscular fibres with which the bloodvessels of the 
uterus interlace. Hemorrhage of any considerable amount cannot take 
place from the cavity of a thoroughly and permanently contracted uterus. 

There are numerous remote causes which contribute directly or indi- 
rectly to the occurrence of post-partum hemorrhage. Prominent among 
them is exhaustion following a prolonged and difficult labor. 

After precipitate labor and sudden expulsion of the child, flooding may 
occur before time enough has elapsed for uterine retraction to take place. 
Overdistention of the uterus, as in hydramnios, multiple pregnancy, etc., 
frequently results in uterine inertia; a distended bladder or rectum tends 
to inhibit normal uterine contractions. The retention of secundines or 
of blood-clots may prevent full retraction of the uterus and the secure 
ligation of its vessels. New growths in the uterus may have a like effect. 
Profound anaesthesia continued for a long time tends to more or less 
complete atony of the uterus. Certain constitutional diseases predispose 
to this accident, as nephritis, extreme anaemia, and haemophilia. Inertia 
uteri, in the final as in the earlier stages of labor, is more common among 
the wealthy than among the poorer classes, owing to luxurious habits, 
lack of exercise, and general laxity of the muscular system, which is the 
rule among the former. Uterine inertia is more commonly observed in 
women who have borne many children and in whom the abdominal walls 
are lax, or in old primiparse who are much debilitated. Veit refers to a 
localized paralysis of that portion of the uterine walls to which the 
placenta was attached as sometimes occasioning obstinate post-partum 
hemorrhage. 



510 PATHOLOGY OF LABOR. 

Second. Placenta praevia exposes to post-partum hemorrhage. The 
Lower Begmenl ol the uterus has but little contractile power at the close 

of labor. Hence, after complete separation of a placenta from the lower 

uterine zone, bleeding may follow from the relaxed lower uterine segment. 

Third. Rarely the hemorrhagic diathesis is encountered in obstetrics 

as in other fields of practice. Here the gravity of the hemorrhage is 

due more to its obstinate persistence than to its rapidity. 

Symptoms. The bleeding may occur before or after the expulsion of 

the placenta. In the majority of cases it takes place within a few 
moments after birth of the child. It may be gradual or abrupt. The 
bleeding may be external, internal, or both. Commonly, when hemor- 
rhage results from uterine inertia, considerable accumulation of blood 
takes place within the uterus. One of the most notable effects of hem- 
orrhage is lessened force and increased frequency of the pulse. If, after 
completion of the second stage of labor, the pulse, instead of gradually 
diminishing iu rapidity, shows a tendency to become accelerated, the 
possibility of hemorrhage should be thought of, and the condition of 
the uterus be determined by the hand on the abdomen. It is a good 
rale never to leave a patient just confined, in whom the pulse rate is 100 
or more to the minute, till assured of the absence of all danger of hemor- 
rhage. 

The patient may herself give the first warning that she is flooding; 
after much bleeding she presents the usual symptoms of acute ansemia. 
The pulse becomes rapid, thready, and, in extreme cases, almost impercep- 
tible. The respirations are shallow and rapid, or gasping; the patient 
restlessly tosses her arms above her head, throwing herself from one side 
of the bed to the other, begging for more air, and she complains of thirst. 
The skin is cold and covered with a clammy sweat. Syncope may occur, 
sometimes to the advantage of the patient, since it may favor thrombosis 
in the uterine sinuses and the arrest of the bleeding. If the hemorrhage 
continues, loss of consciousness, convulsions, and death quickly close the 
scene. 

The existence of external hemorrhage is obvious. In concealed bleed- 
ing the condition is recognized by the presence of some of the above- 
mentioned symptoms. With the hand placed on the abdomen above the 
symphysis, instead of feeling the uterus as a hard globular tumor 
between the umbilicus and the symphysis, it will be found soft, boggy, 
and extending perhaps above the umbilicus; not infrequently, no uterine 
globe can be made out. 

Prognosis. The prognosis must obviously depend upon the amount of 
blood-loss and the nature of the causes which have led to it. The most 
unfavorable cases are those in which, though the hemorrhage is not severe, 
the blood is light-colored, contains no clots, and is indicative of a blood 
dyscrasia. Playfair says: " Recovery is often possible after the vital forces 
have seemingly reached their lowest ebb. If the hemorrhage can be 
arrested while there is still some power of reaction, life may yet be 
saved. Complete recovery after severe post-partum hemorrhage is 
exceedingly slow, and it may be weeks or months before the patient 
regains her usual vigor.' ' 

Treatment. Prophylaxis. Post-partum hemorrhage is a prevent- 
able accident. The preventive treatment must be directed to the uterine 



THE HEMORRHA GES. 511 

retraction. In all cases the band should be held on the abdomen over 
the uterus from the moment the child is born till the placenta is expelled; 
and after the expulsion of the placenta the uterus should be watched, 
for at least an hour, in the same manner by the physician. Any ten- 
dency to abnormal relaxation should immediately be combated by 
friction or, if need be, by more active manipulation. When the uterine 
contractions are feeble, ergot should be given by the mouth or hypo- 
dermically. A sufficient dose ordinarily is a half drachm repeated 
hourly till retraction is fully established. This precaution is especially 
advisable after chloroform anaesthesia. Finally, a firm abdominal binder 
may be used to maintain uterine retraction. When special precautions 
are needed, compresses consisting of folded towels may be placed under 
the bandage, one on either side of the uterus and one immediately above 
it. When the management of the post-partum period is properly carried 
out, the occurrence of grave post-partum hemorrhage must be exceedingly 
rare. 

Active Treatment. The occurrence of post-partum hemorrhage 
demands prompt and vigorous measures for its control. The obstetrician 
should be so familiar with the resources at his command for the arrest 
of uterine hemorrhage that no time may be lost in deciding upon the 
choice of procedure. All needed preparations should be ready for instant 
use should abnormal bleeding occur. 

On the occurrence of hemorrhage of the kind under discussion the 
paramount indication is to secure uterine contraction. The patient 
should be placed on her back, the pillow removed from beneath her 
head, and the foot of the bed elevated. This can all be done by an 
assistant. The hand is swept over the abdomen, moving the abdom- 
inal wall in a circular direction over the uterus. The uterus is quicker 
to respond to vigorous friction than to direct pressure exerted at any 
one point. After the uterus becomes slightly contracted, so that its 
outline is defined, the fingers are pressed deeply into the abdominal wall 
behind the uterus, while the thumb remains resting over the anterior 
surface. Thus the fundus of the uterus rests in the palm of the hand, 
by which it is to be forcibly grasped. If necessary, both hands may be 
used. Such compression tends to expel clots and to control the hemor- 
rhage. 

It may be necessary to introduce one hand into the uterus to remove 
placenta, membranes, or clots. Frequently this manoeuvre will serve 
the double purpose of emptying the uterus and, by the stimulating effect 
of the hand in utero, of provoking strong contractions. 

In profuse or persistent hemorrhage one hand should always be intro- 
duced into the uterus. With the internal hand closed, the other held 
over the abdomen, the uterus may be compressed between the two hands. 
Eaking the uterine wall vigorously with the finger tips is a most effectual 
method of exciting contraction. Hamilton suggests passing the fingers 
of one hand well back into the posterior cul-de-sac of the vagina, while 
the external hand, grasping the fundus through the abdominal wall, makes 
counter-pressure. The uterus is thus strongly anteflexed. Sometimes, 
instead of this, with one or both hands on the abdomen the uterus may 
be crowded down and compressed against one iliac fossa. 

Compression of the abdominal aorta as a temporary means of con- 



512 I'ATIIOLOGY OF LABOR. 

trolling this form of hemorrhage lias long been practised. Its great 
virtue lies in the fact that it can easily and quickly be applied, and it 

often enables the physician to gain time for other procedures. 

While the physician is thus engaged in seeking to stimulate uterine 
contraction, he may direct the nurse or assistant in the use of other meas- 
ures. A full dose of ergot by the mouth, or better, hypudermically, 
because more quickly absorbed, should be given. In the presence of 
exhaustion, stimulation will be demanded: thirty drops to one drachm 
of Bulphurio ether, one-fifteenth to one-twentieth grain of strychnine, or 
several drachms of brandy should be administered hypodermieally. 
The child should at once be put to the breast, as nursing provokes 
uterine contractions. 

As far back as the time of Hippocrates we find mention of the employ- 
ment of various irritating chemical solutions and mechanical substances 
in the cavity of the uterus for the purpose of exciting uterine contrac- 
tions and the arrest of bleeding. The introduction of ice into the 
uterus, while not now used as much as formerly, is still, in the absence 
of other measures, exceedingly serviceable. A lump of ice the size of 
an egg is carried to the fundus of the uterus, and held in position till 
contraction occurs. The application of acetic acid, lemon juice, or alco- 
hol in the uterine cavity is a powerful excito-motor. 

Penrose for many years advocated the employment of vinegar for the 
control of post-partum hemorrhage in the following manner : A clean 
piece of lint or gauze is saturated with vinegar, carried to the fundus of 
the uterus, and squeezed dry, the fluid running down over the walls 
of the uterus. A single application will often be followed by vigorous 
uterine contractions. If necessary, the process may be repeated two or 
three times. A lemon with the rind carefully pared off, and with 
numerous deep longitudinal slits to allow the escape of the juice, has 
been used in the same manner. A grave objection to these measures 
is the risk of infecting the uterus. 

Barnes recommends in extreme cases intra-uterine injections of a solu- 
tion of perchloride of iron. This procedure cannot be too strongly con- 
demned. Not only is the woman exposed to the danger of pulmonary 
embolism, but a mealy mass of blood-clots is left in the uterus, which may r 
serve as a nidus for the growth of putrefactive and pathogenic bacteria. 

The intra-uterine injection of hot sterilized water has recently come to 
be regarded as one of the most reliable means we possess for the control 
of post-partum hemorrhage. In many of the Continental hospitals, and 
very largely in America, this method has become the routine treatment 
for uterine hemorrhage. The external genitals should be well smeared 
over with carbolized vaseline or olive oil, to relieve pain from contact of 
the hot water with the skin. After removing the placenta and all clots 
from the uterus and vagina, a long douche-tube, preferably of glass and 
with openings only at the extreme end, is carried to the fundus. Several 
gallons of water are injected at a temperature of 48° C. (120° F.), or 
as hot as can be borne. The temperature of the water should not exceed 
1 25° F., lest the uterine muscle be paralyzed. Neither should it be below 
115° F., as merely lukewarm water favors hemorrhage. The tempera- 
ture should be accurately determined by a bath thermometer. Either a 
fountain or a Davidson syringe may be used, preferably the former. 



THE HEMORRHAGES. 513 

If the hemorrhage be not checked by this means the injection should 
at once be repeated, after adding to the sterilized water enough pure 
acetic acid to make a 3 per cent, solution, 4 fluidouuces to the gallon. 
This is aseptic, and is free from the dangers of vinegar or of the iron 
solutions. Its action is usually immediate and permanent. 

Occasionally these injections will fail to stop the bleeding. The uterus 
should then be tamponed with strips of iodoform gauze, and often this 
procedure, if done properly, will control a hemorrhage which resists all 
other measures. The method is as follows: Three strips of plain steril- 
ized gauze are cut, each three inches wide and about ten feet in length. 
The patient lies on her back across the bed, each thigh being supported 
by an assistant, and a vaginal douche of sterilized water is first given. 
The uterus is theu irrigated with the same solution. Each lip of the 
cervix is seized with vulsellum forceps or a tenaculum and drawn down 
toward the vulva. An assistant holds the tenacula. The operator now 
makes pressure on the fundus of the uterus with one hand, while with 
the other he grasps one end of a strip of gauze in a long uterine dressing- 
forceps and carries it to the fundus of the uterus. Successive layers of 
gauze are now deposited one on the other, in accordion-like manner, with 
moderate firmness until the uterus is completely filled. The ends of the 
gauze may be left projecting into the vagina, in which a little gauze may 
be loosely placed. If strict antiseptic precautions have been observed 
the tampon may safely be left in the uterus twenty-four hours. It may 
be necessary to remove it sooner than this, if the hemorrhage is not 
fully controlled. A renewal of the t-ampon is very seldom necessary. 

In one or two reported instances even this has failed, hemorrhage 
recommencing with each withdrawal of the gauze. Soaking the gauze 
in a saturated solution of alum w T as finally resorted to before permanent 
cessation of the flow of blood occurred. 

Treatment of Acute Anaemia. The principal measures available for 
restoring the volume of the circulatory flow are transfusion, auto-trans- 
fusion, subcutaneous and intravenous injections of the normal salt solu- 
tion, and rectal injections of this solution. 

Transfusion, or the introduction of blood from one person directly into 
the venous circulation of the patient, is a method which formerly was 
much in vogue, but is now seldom practised. 

Auto-transfusion consists in forcing the blood from the extremities 
into the trunk and brain, and retaining it there by bandaging the extremi- 
ties. An Esmarch bandage can be applied to one arm, beginning at the 
fingers, and to the opposite leg and thigh, beginning at the toes. Only 
two extremities should be constricted at once. These bandages may be 
left on twenty minutes to half an hour, and before their removal the 
opposite leg and arm should be bound in the same manner. By thus 
alternating the constriction, the danger of thrombosis and embolism is 
diminished. 

The use of the normal saline solution, introduced into the circu- 
lation either subcutaneously, directly into the veins, or by high rectal 
enemata, is the means now most generally relied upon. The normal 
saline solution consists of a solution of sodium chloride of the strength 
of six-tenths of 1 per cent, in sterilized water; before using, it should 
be raised to a temperature of 37.5° C. (98° to 100° F.), and filtered 

33 



51 i PATHOLOGY OF LABOR. 

through absorbenl cotton. This solution can be prepared with sufficient 
accuracy by adding a teaspoonful of Bait to a quart of sterilized water. 
Subcutaneous injections may be made with Munchmeyer'e apparatus, or 
in the absence of this by means of an aspirating net-die attached to a 
rubber tube having a funnel, fountain syringe, or a rubber bag at the 
other end. From one to three pints of fluid may he w<cd. These injec- 
tions may he made beneath the skin of the abdomen, thigh, or back, 
or better, behind the mammary gland. High rectal enemata of the 
same solution may be given at frequent intervals and in as large quan- 
tities as can be retained. The patient may also be encouraged to drink 
freely of water, yet stomach absorption is usually in abeyance. 

Intravenous injections of the normal salt solution are given in the 
following manner: A funnel holding a quart of water, to which is 
attached a rubber tube terminating iu a tine pointed glass tip or canula, 
is rilled with the previously prepared salt solution, which must be abso- 
lutely sterile and free from mechanical particles. The temperature of 
the solution should be about 37.5° C. (100° F.). The integument over 
the median basilic vein is now carefully disinfected, and the vein made 
prominent by a snug bandage applied about the arm below the shoulder. 
An incision one inch in length is made parallel with and at one side of 
the median basilic vein. The vein is now freed from its attachment for 
a distance of half an inch with the handle of the scalpel. An aneurism 
needle threaded with a double silk ligature is introduced beneath the 
vein, the ligature cut, and the aneurism needle removed. One of the 
ligatures is drawn into the lower angle of the wound, the vessel ligated, 
and the ends of the ligature cut away. The constricting bandage above 
the field of operation may be removed. The second ligature is drawn 
upward toward the upper angle of the wound and one knot loosely 
taken. Having the canula or small glass tip now close at hand, with a 
gentle stream running, the vein is picked up with a pair of dissecting 
forceps, and an oblique upward slit made with the scissors, care being 
taken not to cut through the entire calibre of the vessel. The canula is 
quickly introduced into the vein, the water running gently all the while, 
and is retained in position by drawing snugly the single knot of the 
ligature. The amount of solution introduced will vary from one to three 
pints, depending upon the condition of the patient. The height at which 
the glass funnel is held will determine the force of the stream; usually 
three feet above the patient's body will be sufficient. When enough 
fluid has been introduced, as indicated by the radial pulse, the canula 
should be withdrawn, the ligature quickly tightened, a second knot taken, 
and the ends of the ligature cut away. The vein between the ligatures 
should now be completely divided, the skin incision closed by two or 
three sutures, and a dressing applied. 

Prolonged irrigation of the bowel with the hot saline solution at a 
temperature of 120° F. has recently been praised for the treatment of 
anaemia. A double-current canula is employed. As much as fifteen 
gallons of the salt solution may be used in this manner. Better results, 
it is claimed, are obtained than with subcutaneous injections. 

Convalescence from the anaemia resulting from severe post-partum 
hemorrhage is slow and tedious. The patient should not be allowed to 
nurse her child nor to assume the upright position for some time. A 



THE HEMORRHAGES. 515 

light but nutritious diet should be ordered. Alcohol in the form of light 
wine or beer may be advisable. A patient who has suffered from post- 
partum hemorrhage should not be allowed to sit up for at least four 
weeks after her confinement. The employment of iron in some form, as 
a tonic and haBmatinic, is indicated. 

Secondary Post-Partum Hemorrhage. 

Hemorrhage from the uterine cavity occurriug later than six hours 
after delivery is called secondary post-partum hemorrhage. Care must 
be taken not to mistake a profuse lochial discharge, perhaps continuing 
longer than usual, for true secondary hemorrhage. When in a given 
case bleeding occurs after the third day in any considerable quantity, 
a careful examination should at once be made, since the proper treatment 
to be adopted depends entirely upon an accurate determination of the 
cause of the hemorrhage. 

The causes of secondary hemorrhage, arranged as nearly as possible in 
the order of their relative importance, are as follows : Retention of por- 
tions of placenta and membranes; clots in the uterine cavity; irregular 
and inefficient uterine contractions; displacements of the uterus; dis- 
lodgement of thrombi from the uterine sinuses; uterine fibromata and 
polypi; constitutional causes; overdistention of the bladder or rectum. 

By far the most frequent cause of hemorrhage during the puerperal 
state is retention within the uterine cavity of fragments of the placenta 
or membranes. This retention may be due to the carelessness of the 
obstetrician, particularly in the conduct of the third stage of labor, or 
in the examination of the placenta. Often it is due to causes entirely 
beyond his control, such as adherent placenta, in which it is impossible 
to remove all placental tissue, or to placenta succenturiata or spuria. So 
commonly is secondary hemorrhage attributable to retained secundines 
that, in all cases in which profuse hemorrhage occurs after the third day 
following confinement, the obstetrician is justified in exploring the interior 
of the uterus at once, with full confidence that the cause of the hemor- 
rhage will be found. To properly carry out the examination the patient 
should be anaesthetized. The cavity of the uterus can now be care- 
fully explored and fragments of placenta, membranes, or clots removed. 
The finger or, better, the blunt curette may be used. The interior of 
the uterus should be thoroughly irrigated with a hot weak antiseptic 
solution, as a 2 per cent, solution of creolin or a 5 per cent, solution of 
boric acid. If the hemorrhage persists, the curage or curettage must 
be repeated. 

Clots in the uterine cavity may give rise to hemorrhage if they are 
of sufficient size to interfere with the firm contraction of that organ. 
Irregular and inefficient contraction of the uterus favors the formation of 
these clots; rarely does it become necessary to remove them. While their 
expulsion may be attended with a gush of blood, the bleeding ceases 
as soon as the uterus is empty. 

Normally after labor the uterus is in a position of marked antever- 
sion. It may, however, from various causes, become displaced backward 
or upward. The cause of this condition may be an improperly applied 
abdominal bandage or pad, or the undue pressure of a greatly distended 



516 P iTHOLOQY OF LABOR. 

rectum or bladder. The resull of such displacements is flexion of the 

uterine canal, with consequent accumulation of blood and lochia above 
the >eat of flexion. The bleeding from this cause is more apt to be a 

persistent oozing than a free hemorrhage. The treatment consists in 
removing the cause and in irrigating the uterine cavity with hot Steril- 
ized water. 

I [emorrhage due to displacement of thrombi in the uterine sinuses may 

rarely occur. If, after exploring the cavity of the uterus for clots or 
retained secundines, nothing he found to account for the hemorrhage, the 
possibility of dislodgenientof thrombi should be suspected, and the bleed- 
ing controlled by packing the uterus with strips of iodoform gauze. 

Uterine fibromata and polypi may occasion secondary hemorrhage; 
their presence is recognized by a bimanual examination and by the 
sound passed into the uterus. The bleeding from a submucous fibroid 
can usually be controlled by small doses of ergot, opium, the local appli- 
cation of ice, or hot vaginal douches. If a small pedunculated polypus 
be the cause of the hemorrhage, it can easily be removed by torsion or 
the wire ecraseur. The full discussion of this subject belongs more 
properly to the gynecologist. 

Malignant disease of the neck or body of the uterus may very rarely 
be the cause of hemorrhage in the puerperium. In such cases hot 
vaginal douches may suffice for the time. 

It must not be forgotten that a puerperal hemorrhage may be due to 
inversion of the uterus. 

Various constitutional conditions and diseases may favor hemorrhage 
during the puerperal state. Thus, sudden and profound mental shock, 
a debilitated condition of the system, as that dependent upon advanced 
syphilitic or tubercular disease, some of the acute infectious diseases, as 
scarlatina, diphtheria, and malarial poisoning, and finally, the influence 
of causes inducing uterine congestion, such as sudden chilling of the 
surface of the body, too early assumption of the upright position after 
delivery, etc., sometimes give rise to uterine hemorrhage during conva- 
lescence from labor. 

A distended bladder or rectum after labor is liable to be attended 
with uterine hemorrhage, since by its reflex effect it inhibits uterine 
contractions. 



CHAPTER XXIII. 

ECLAMPSIA. 

Definition. By the terms eclampsia, puerperal eclampsia, and puerperal 
convulsions is meant, in modern medicine, an acute, morbid condition, 
making its advent during pregnancy, labor, or the puerperal state, which 
is characterized by a series of tonic and clonic convulsions, affecting first 
the voluntary and then the involuntary muscles, accompanied by com- 
plete loss of consciousness, and ending in coma or sleep. The disease 
may eventuate in death or recovery (Charpentier). 

Frequency. Eclampsia is most frequent in the later months of preg- 
nancy, less frequent in labor, and least frequent in the puerperium. Its 
occurrence is given by various authorities as 1 in 500 pregnancies; 1 in 
250 to 300; 1 in 350 to 500— a range of 0.2 to 0.4 per cent. It is 
said that the complication appears in 1 per cent, of all cases of albumi- 
nuria of pregnancy. Schauta places it at 0. 25 per cent, of all pregnancies. 

Symptomatology. Symptoms of eclampsia may be classified as those of 
the prodromal period, or pre-eclamptic state, and those of the attack. In 
the latter, moreover, there are three'stages : (1) invasion; (2) tonic and 
clonic convulsions; (3) coma.* 

Prodromal Period, or Pre-eclamptic State. These symptoms 
are of great importance, for to the experienced they are a certain sign of 
an impending attack. As in epilepsy, a well-defined aura may give the 
warning. Following it, or occurring without it, there may be headache, 
tinnitus aurium, visceral disturbances, such as dizziness, amblyopia, amau- 
rosis, epigastric pain, digestive and nervous disturbances, and a feeling 
of general debility. These occur with a fair degree of constancy in about 
one-fourth of all cases of eclampsia. Less often symptoms of involve- 
ment of the brain occur, somnolence, stupor or insomnia, vertigo, vomit- 
ing, mental excitement, or despondency. All of them may subside, in 
which case appetite returns, perspiration and diuresis become more 
abundant, and the patient falls into refreshing sleep. Usually the issue 
is not so happy, and the premonitory signs, or pre-eclamptic state, after 
having existed for hours or days, give way to those of the 

Stage of Invasion. The eyes stare, the lids twitch convulsively, 
and the pupils, at first contracted to a pin-point, dilate widely. During 
the attack they are totally insensible to light. The face becomes cyanotic, 
and the muscles about the ala3 of the nose and the mouth jerk rapidly 
and convulsively. The mouth is drawn to one side, the head rotates, 
and the eyeballs are rolled up. This gives way to the 

Stage of Tonic and Clonic Convulsions. The movements, in 
the beginning confined to the head, extend to the neck, trunk, and 
extremities, rarely, however, passing to the legs. The neck is bent 
backward and fixed finally with the back in an opisthotonic curve. 
The arms are extended and rigid, the hands closed, with the thumbs in 

(517) 



518 PATHOLOGY OF LABOR. 

the palms, and the knees Hexed on the abdomen. The tonic convulsions 
involve the respiratory muscles, including the diaphragm. During the 
height of the paroxysm there may he one or two spasmodic respirations, 
although the chest muscles are strongly contracted. The tongue is par- 
tially protruded, and, being often bitten, the frothy saliva is tinged with 
red. L «sof sensation and consciousness is complete. Tonic convulsions 
Last from ten to twenty seconds, and are succeeded by clonic spasms. 

As in the early part of the attack, the clonic convulsions begin in the 
face, which is horribly distorted, and extend over the body. Respira- 
tion becomes irregular and noisy. The jaws open and close rapidly, and 
the tongue may again be bitten. As a rule, the body retains its previous 
position, but it may become necessary to hold the patient in bed. Toward 
the close of the attack respiration becomes full, labored, and stertorous. 
After one or two minutes the patient passes into the 

Stage of Coma. This period lasts about half an hour. During its 
continuance consciousness and sensation slowly return. If recovery is 
to take place, the woman falls into a deep sleep, and wakes to ask con- 
fusedly what has happened. This unconsciousness has led mothers to 
deny their offspring born during eclampsia. 

It is an •exceptional occurrence for one attack only to occur. The first 
is usually followed at varying intervals by others. In case the seizures 
are uncontrollable and death is to ensue, the temperature rises progres- 
sively to 104° F. or more. The pulse is small, wiry, frequent, a semi- 
conscious state supervenes, and death takes place during this period or 
in an attack from pulmonary oedema, cerebral congestion, hemorrhage, or 
exhaustion, or some days later from an intercurrent puerperal affection. 

The Effect upon the Foetus and Labor is almost constant. 
The former suffers decidedly — one attack may be sufficient to kill it. 
In twin pregnancy one or both may die. The child may survive several 
attacks. Winckel has observed a remarkable fact, that, if the foetus is 
killed and pregnancy not at once interrupted, the onset and course of 
labor may be free from convulsions. 

Pregnancy is apt to be terminated shortly, an accident easily under- 
stood in view of the shock, nervous disturbance, and uterine contractions. 
If the seizure occurs in labor, the pains are increased by the general mus- 
cular excitement, so much so that the child may be born before the 
physician is freed from his care of the mother. 

The kidneys are involved in about two-thirds of the cases of eclampsia. 
In 84 per cent, the urine contains albumin in quantity varying up to 
2.5 per cent, or more. Albuminuria, an important prodrome, increases 
with each attack, and decreases rapidly after their cessation. It usually 
contains sugar and formed elements, red and white corpuscles, and casts. 
In other words, symptoms of acute renal congestion are present. 

Etiology. The last word has by no means been spoken on this question, 
but this much may be stated with positiveness, that eclampsia does not 
always depend on albuminuria and kidney change, and, further, that 
albuminuria does not constantly accompany the convulsions. As may 
be supposed, many theories have been advanced to account for the phe- 
nomena, which, for a clear understanding of the subject, must be looked 
into and appreciated. 

The theory of Frerichs, that eclampsia is ursemic, and that of Petroff 



ECLAMPSIA. 519 

and Spiegelberg, that it is due to amnionaemia, have been effectually dis- 
posed of by modern investigators, who have proved that there was abso- 
lutely no retention of nitrogenous products in the important organs. 
Moreover, on recovery the amount of these products excreted was not 
excessive — in fact, was only equal to the amount secreted in starvation. 
Traube, Murck, and Rosenstein have held that hydremia was the pre- 
disposing cause of eclampsia; but there stands in the way the fact that 
eclampsia has occurred where there was no hydrsemia, and in cases of 
pregnancy where there were no contractions, the latter being the corner- 
stone of the theory, since it was held that the uterine contractions were 
responsible for increase of aortic pressure. Landois has claimed that 
hyperemia, particularly a venous stasis in the brain between the corpora 
quadrigemina and spinal cord, is likely to produce epileptiform convul- 
sions, while Galabin holds that eclampsia is due to anaemia of the cortical 
gray substance. Stumpf pins his faith to acetone as the exciting cause, 
since it has been found in the urine, and may be present in the exhala- 
tions. Its presence is not constant. 

Fleischer and others were led to the belief that the cause of eclampsia 
was to be found in the extractive materials present in the urine, and that 
when they were retained in abnormal amount in the body, convulsions 
occurred, by the following facts : (1) The symptoms of eclampsia resem- 
ble those produced by poisonous material circulating in the blood ; (2) 
in eclampsia the amount of urine excreted is diminished (whether due to 
compression of the ureters or not, we cannot say); (3) the danger lessens 
and the tendency to convulsion diminishes from the moment the amount 
of urine passed in twenty-four hours is markedly increased. This is 
the theory of toxcemia, which has been ably supported by Bouchard in 
his experiments upon animals. His statement is that eclampsia is an 
intoxication closely resembling uraemia (the latter word being used in 
its broadest sense), ' ' to which, in unequal portions, all the poisons intro- 
duced normally into the organism, or found therein physiologically, con- 
tribute when the quantity of poison formed or introduced in twenty-four 
hours can no longer be eliminated in the same time by the kidneys, which 
have become scarcely sufficiently permeable." (The reader is referred 
for further elaboration of the theory to Bouchard's "Auto-intoxication," 
Chapter XV.). 

Schmorl 1 ascribes eclampsia to an intoxication by coagulation, pro- 
ducing ferments, which ferments originate in the placenta. 

Schmorl gives the following reasons for this conclusion : 

1. The clogging of the vessels, reported by himself, Klebs, and 
Lubarsch, which is undoubtedly of primary origin, is like those throm- 
boses which we observe in man and animals when coagulation-producing 
ferments are introduced into the blood. 

2. Klebs' opinion that the coagulation-ferments are produced by the 
destruction of the embolic liver cells is wrong. 

3. According to Schmorl' s, Lubarsch' s, and Jung's investigations, 
placenta-cells pass into the blood regularly, which cells, as experiments 
on animals show, have a tendency to provoke coagulation, at least when 
present in large number. 

i Path. Theses, Halle, 1892, vol. ii. p. 155. 



520 PATHOLOGY OF LABOR. 

Schmorl, 1 in another place, ascribes an important r61e to this throm- 
bosis <>f the blood j stating that the thrombosis may be embolic in origin, 
but most often is primary. 

In still another place 3 he states that the parenchymatous cells entering 
the circulation interfere with the chemical composition of the blood. . . . 
That in eclampsia coagulation of the blood occurs owing to parenchyma- 
tous embolism. lie claims to be able to demonstrate iii most cases of 
eclampsia the presence of thrombi in the arteries, and more especially in 
the veins. According to Schmorl's opinion, a toxic substance contained 
in the blood is responsible for eclampsia; experiment has shown that 
dying cells produce a ferment which coagulates blood, but he thinks 
that our knowledge about the metabolic process in the placenta is not 
enough to place the origin of this ferment in this organ. 

Lubarsch 3 cannot accept SchmorFs opinion that the role of the liver 
cells in eclampsia is secondary. . . . From experiments and obser- 
vations he believes that, owing to the penetration of liver cells into the 
blood current, a coagulation-producing ferment is produced. Lubarsch 
agrees with Schmorl that in some cases of eclampsia the thrombi are of 
primary origin, entirely independent of the liver cells. He nevertheless 
sees in the liver cells the factor for the production of coagulation and 
thrombosis with all its consequences. He believes the liver-cell embol- 
ism plays an important part in eclampsia, and that attacks due to liver- 
cell embolism will expose the organism to the formation of more thrombi 
aud infarctions. He further believes that embolisms due to cells are not 
the cause of diseases combined with convulsions, but that they are the 
consequence of the convulsions. 

According to Lubarsch 4 the liver-cell embolism is either of a traumatic 
nature or due to toxic infection, and appears to take place in all regions 
where, owing to the presence of necroses and hemorrhages of the liver, 
the tissues are subjected to increased pressure. 

Volhard, 5 F., observed that the urine passed after an eclamptic attack 
was increased in toxicity, was imbued with specific properties, producing 
during life thrombosis when injected into the veins. This confirms 
SchmorFs statement that eclampsia is an auto-intoxication produced by a 
coagulation-producing poison. This substance, according to Volhard, 
does not injure the epithelium of the kidneys directly, but indirectly by 
clogging the nutritive vessels. 

Luelwig and Savor 6 consider eclampsia as a process due to auto-intoxi- 
cation by a ferment which is the product of metabolic processes, and 
masked in the organism during pregnancy, owing to the derangements in 
the metabolic processes. The action of the ferment is expressed by the 
symptoms of eclampsia. The removal of the ferment by the kidneys 
takes place after the convulsion. Whether this ferment is due to the 
lesions in the liver, or presents a connective link in the synthesis of 
urine, further investigation alone can determine. 

1 Path, anatomische Untersuchungen uber puerperal Eclarapsie. Leipzig, 1893. 
- Pathologische anatomische Befunde bei Eklarnpsie. Trans, of the German Gynecol. Soc, Leip- 
zig, 1891. p. 179. 

3 Zur Lehre von der Parenchym. Embol. Fortsch. d. Med., 1893, vol. xi. p. 806. 

4 Die puerperal Eklarnpsie. Lubarsch u. Ostersay, 1898, vol. i. p. 120. 

B Experimental und kritische Studien zur Pathogenese der Eklarnpsie. Monatsch. f. Geb. u. Gyn., 
1897. Bd. v., II. v. 

c Experiment. Studien zur Pathogenese der Eklarnpsie. Monatsch. f. Geburts. u. Gynaekol., 1895, 
Bd. i., H. v., p. 447. 



ECLAMPSIA. 521 

This is where we stand to-day in regard to the etiology of eclampsia. 
As to the nature of the poisons, we are much in doubt, even if we accept 
all of Bouchard' s statements. According to his experiments, urea contrib- 
utes one-eighth of the total toxicity of eliminated urinary products, color- 
ing matters, and other substances fixed by charcoal (leucin, ty rosin, etc.), 
two-fifths, the remainder being made up of mineral salts, chiefly of potas- 
sium. Since these statements are based on animal experimentation (other 
than human), they are to some extent unreliable. This short review of 
the theory of toxaemia explains the reason for the existence of many of 
the exciting and predisposing causes of eclampsia — e. g. y any interference 
with the permeability of the renal filter. 

Predisposing Causes may be classed under three headings : (1) All 
chronic and acute forms of kidney disease, all nephritis, old and recent 
inflammatory changes, the recent " kidney' 7 of pregnancy, which result 
in failure of elimination, hydremia, albuminuria, and oedema. (2) 
Long-continued and marked retention of urine, particularly that pro- 
duced by pressure on the ureters. This pressure may be exerted by (a) 
an abnormally enlarged uterus, as in twin pregnancy, hydramnios, etc. ; 
(b) small pelves; (c) large foetus or foetal head. In proof of this cause 
stand the striking figures of the occurrence of eclampsia in 11 per cent, 
of multiple as against the 1.1 per cent, of single pregnancies. (3) Very 
young or very old primiparae are particularly prone to attack on account 
of their rigid muscles and the lack of room in their pelvic and abdominal 
cavities. The proportion of eclamptic primiparae to multiparas is three 
to one (Schauta.) 

Exciting Causes, acting in the presence of predisposition, may lie in (1) 
sudden, partial, or complete suppression of urine; (2) constipation; 
(3) painful uterine contractions, an unyielding external os or introitus 
vaginas in primiparae; (4) prolonged and exhausting efforts at expulsion; 
(5) profound emotion. The eclamptic convulsion once established, the 
slightest shock, external or internal, is sufficient to determine a par- 
oxysm. 

The Pathology of the condition is, as may readily be imagined, more 
than obscure. Post mortem the changes are an anaemia of the organs 
generally, a congestion of the cerebral cortex, occasional slight hepatic 
apoplexies, and a fluid condition of the blood. The chief changes, dimin- 
ished urinary toxicity and corresponding increase in amounts of circu- 
lating poisons, are rather to be found intra vitam than after death. 

Diagnosis of puerperal eclampsia, at first sight, appears to be simple, 
but to make a careless diagnosis is to invite a serious mistake sooner or 
later. The mere concurrence of a convulsive seizure with pregnancy or 
the puerperium does not per se warrant the conclusion that it is eclamptic. 
There are four conditions to which the pregnant parturient or the puer- 
peral woman is subject which may be mistaken for eclampsia. They 
are (1) epilepsy, (2) hysteria, (3) apoplexy, and (4) meningitis. 

Epilepsy is distinguished by the history of former and repeated attacks, 
by the presence of urine, normal in amount, free from albumin and casts 
(except in intercurrent nephritis), by coma more complete, by the absence 
of oedema and of prodromes, saving the usual aura. The epileptic falls 
suddenly with a sharp cry. Hysterical patients are conscious, as a rule, 
in the attack, the muscular contractions are less severe, there is never a 



522 I'ATIIOLOGY OF LABOR. 

coma. They -cream, Laugh, or cry, oedema is not present, and they pass 
large quantities of clear, pale urine. Here, also, a history of previous 

attack- may be elicited. Apoplexy is rare in pregnancy. It comes on 
Suddenly without prodromata. Coma supervenes early. Convulsions 

are absent, and paralysis evident. Meningitis Is even more rare. The 
history will aid materially in forming an opinion. The convulsions are 
Local as opposed to general in eclampsia, and they increase in severity by 
easy stages. Fever always precedes their appearance. 

1 n all cases of doubt careful attention should be paid to the urine, and 
its quantity, and the presence of albumin, sugar, blood, and casts thor- 
oughly investigated. With these aids to the clinical picture, the attend- 
ant should have little difficulty in forming a correct opinion. 

Prognosis. Puerperal eclampsia is a most serious affection. Even at 
the present day the maternal mortality is 30 per cent., that of the child 
50 per cent. The pregnant woman who is suffering from decided symp- 
toms of toxaemia, albuminuria, and the quantity of whose urine is daily 
diminishing, is in great danger of an attack. As the albumin increases 
and the quantity of water passed in the twenty-four hours diminishes, 
the danger becomes more imminent. The peril becomes more remote as 
the converse takes place. Urea, as to amount excreted, is a better guide 
in prognosis, as shown by Bouchard and Davis, than albumin. The 
latter found toxic symptoms to diminish with its increase. The earlier 
in pregnancy the seizure occurs the worse the prognosis. Schauta has 
proved time and again that all disturbances, even those of the kidneys, 
decline after the death of the child; consequently the sooner it dies in 
repeated attacks the better the prognosis. An early occurrence of pro- 
fuse sweating is an encouraging sign. Prognosis is most unfavorable 
when the attacks occur in pregnancy, when they succeed each other 
rapidly, and become progressively more severe, and when they have lasted 
for some time before aid is secured. Chloroform treatment has lessened 
mortality in these cases. To sum up, prognosis is favorable when — 

1 . The attacks are infrequent and mild. 

2. The child dies. 

3. The patient is conscious in the intervals. 

4. There is a small amount of albumin. 

5. A fall of temperature occurs. 

6. The attacks occur late in labor or during the puerperium. 
Prognosis is unfavorable when opposite conditions prevail. The child 

born of an eclamptic mother has a diminished vitality, and often dies in 
the first twenty-four hours. 

The causes of death in the mother are exhaustion, apoplexy from forcible 
rupture of the cerebral vessels, asphyxia due to spasm of the muscles of 
the glottis and of respiration, pulmonary and cerebral cedema, the result 
of serous effusion from distended capillaries, cerebral congestion, of which 
coma is a symptom, and paralysis of the heart. The last, when it occurs 
in the general spasm, causes instant death. The causes of the child's 
death are the mother's convulsions and the pressure exerted by them, 
asphyxia from compression or oedema of the placenta, or the excess of 
carbon dioxide in the blood, possibly direct poisoning by the toxic mate- 
rials in the maternal circulation. 

Treatment. Granted the contention, which, if not absolutely correct, 



ECLAMPSIA. 523 

is at least the best theory of etiology we have to-day, that eclampsia is 
the result of toxaemia, then of the two treatments of eclampsia, prophy- 
lactic and curative, the former is by all odds the more important, since 
the seizure is generally preventable. This is an opinion which is shared 
by many prominent American as well as foreign obstetricians. 

(a) The Preventive Treatment. What symptom or sign, or 
what combination of symptoms or signs, is at our disposal for the 
recognition of the pre-eclamptic state in time to prevent the subsequent 
eclamptic convulsions? 

The symptoms of the state preceding an eclamptic attack include a 
rapid pulse, accompanied usually by high arterial tension, loss of appe- 
tite, gastric and intestinal disturbances, headache, lassitude mental and 
physical, a gradual or rapid diminution of all the excretions, both liquid 
and solid — in a word, what one would expect to observe from the intro- 
duction or retention in the blood of some toxic material. 

Aside from the direct examination of the blood itself, the condition of 
the urinary secretion offers us the most convenient physical sign or clin- 
ical index of this pre-eclamptic state. The amount of urine passed in 
twenty-four hours is not always a reliable guide of kidney failure. Albu- 
minuria, as is well known, may be absent before, during, and even after 
an eclamptic seizure. The amount of urea excreted is a far better guide, 
as has been shown by Bouchard, of Paris, in the non-pregnant condition, 
and recently by Dr. E. P. Davis, of Philadelphia, in pregnancy; for 
the latter found that when urea fell to 1.5 per cent, stimulation of the 
excreting processes resulted in distinctly favorable results in all cases 
in which toxic symptoms were previously present. It is not to be 
inferred from this that urea causes the convulsions, for large quantities 
of urea may be injected into rabbits without producing toxic symptoms. 
Indeed, Bouchard found that bile had nine times the toxic power of urea. 
It is generally accepted that the diminution in the amount of the urea 
excreted indicates kidney inadequacy; but it is not always a reliable 
guide. There are other substances in the urine with as great or greater 
poisonous qualities. Urea may be found in sufficient quantity and an 
eclamptic attack occur. Bouchard determined the toxicity of the urine 
by injections of the same into the circulation of rabbits. His experi- 
ments show that the normal healthy urine is toxic in the proportion of a 
certain unit per kilo by weight of the rabbit. In kidney insufficiency, 
when some poison or poisons are retained in the circulation, the toxic 
properties of the urine diminish, and it requires more of the urine to the 
kilo by weight of the rabbit to produce toxic symptoms in the animal. 
This gives us a delicate test for determining kidney inadequacy in doubt- 
ful cases. Bouchard's experiments further show that in renal insuffi- 
ciency the poisons retained in the patient's blood arise from: 

1. Food, especially nitrogenous food, as muscle, and food containing 
the salts of potassium. 

2. Bile. 

3. Putrefaction in the intestines, and absorption of its products. 

4. Toxic materials constantly being produced by the metabolism of 
all the cells of the body. 

To this last may be added the metabolism of the foetal tissues, as this 
greatly increases the toxic material in the mother' s blood, for, clinically, 



524 PATHOLOGY OF LABOR. 

it is a familial' fad that when the foetus dies in iUero s or is delivered in 
the case of a living child, the eclamptic seizures usually cease. 

Auaiu, Winckel 8 observation, that in twin and triple pregnancies 
tli.-re is a greater predisposition to eclampsia, has been verified by others. 
Moreover, the tendency to eclampsia becomes greater proportionately 
with the advance of gestation and the consequent increase of foetal metab- 
olism. 

Farther, we know that the maternal mortality diminishes progressively 
from the ante-partum to the post-partum states, namely, that it is greatest 
when eclampsia sets in daring pregnancy, is less during labor, and lowest 
of all when the attack occurs for the first time after the birth of the child. 
Thus, the mortality during eight years at the Boston Lying-in Hospital, 
as has been shown by Green, 1 was : ante-partum eclampsia, maternal 
mortality, 46 per cent.; foetal mortality, 69 per cent. Intra-partum 
eclampsia, maternal mortality, 25 per cent.; foetal mortality, 25 per 
cent. Post-partum eclampsia, maternal mortality, 7 per cent. 

Our present knowledge of the causation of puerperal eclampsia, meagre 
though it be, furnishes us, if not with the key to the successful preventive 
treatment of the condition, still with a working hypothesis, namely, the 
early recognition of the pre-eclamptic state. To accomplish this some- 
thing more than a perfunctory monthly or bimonthly examination of the 
urine for the presence of albumin is called for, since non-albuminuric 
eclampsia occurs in from 9 to 16 per cent, of cases, and it would appear 
to be quite as fatal as an eclampsia accompanied by albuminuria, if not 
more so. Something more is demanded than the late recognition of 
renal insufficiency, as it shows itself in a marked diminution in the quan- 
tity of urine, specific gravity of the same, and amount of urea excreted. 

When obstetricians shall accustom themselves to watch their cases of 
pregnancy, not only for the physical signs of pronounced renal inade- 
quacy as an index of an approaching eclamptic attack, but also for the 
general symptoms of the overcharging of the blood with toxic material 
— as high arterial tension, headache, gastric disturbances, physical and 
mental lassitude — and further for failure of the bowels, liver, skin, and 
lungs properly to perform their functions, and intelligently treat the 
same, then, and then only, shall they have done their whole duty by their 
patient, and done all in their power to correct the pre-eclamptic condition 
and avert an impending eclampsia. 

The writer's line of treatment of this pre-eclamptic state may be formu- 
lated somewhat in the following manner : 

1. Reduce the amount of nitrogenous food to a minimum. 

2. Limit the production and absorption of toxic materials in the intes- 
tines and tissues of the body, and assist in their elimination by improving 
the action of (1) the bowels, (2) the kidneys, (3) the liver, (4) the skin, and 
(5) the lungs. 

3. If necessary, remove the source of the foetal metabolism and of periph- 
eral irritation in the uterus by the emptying of that organ. 

The first indication — reduction of the amount of nitrogenous food to 
a minimum — can best be fulfilled in an exclusive milk diet, to which, as 
the symptoms subside or disappear, can be added fish and white meats. 

1 Green : " Puerperal Eclampsia ; Experience of the Boston Lying-in Hospital in the Last Eight 
Years," American Journal of Obstetrics, 1893, xxviii. 18-44. 



ECLAMPSIA, 525 

It is not only safer, but less trying to the patient, to commence with an 
absolute milk diet, than to compromise and afterward be compelled to 
cut off all but the milk. For the second indication — that of elimination 
— an abundant supply of pure air and water must be assured. This 
may be assisted by moderate exercise or light calisthenics, or massage, 
in certain instances. For the bowels, the writer advocates daily doses of 
colocynth and aloes at bedtime, followed by a saline in the morning. 
For the liver an occasional dose of calomel and soda at bedtime, followed 
in the morning by one of the stronger sulphur waters, as Eubinat, Villa- 
cabras, or Birmenstorf. Increased diuresis is secured by maximum doses 
of glonoin. The action of the skin is encouraged by encasing the body 
in wool or flannel underclothing, by massage, by the warm bath, hot 
bath, hot pack, or hot-air bath, according to the urgency of the case. 

It is well in instances of eliminative insufficiency to give at bedtime 
twice weekly, or more frequently, if necessary, a tablet composed of 
calomel, digitalis, and squill, each one grain, and muriate of pilocarpine, 
one-twentieth of a grain. This is followed in the morning by a full dose 
of Villacabras water. A decided diaphoretic-diuretic action follows the 
administration of such a combination, with the additional prompt action 
upon the liver and intestines as well. So of the five eliminative pro- 
cesses, four are stimulated to more energetic action by its use. 

The fact that jaborandi has been practically abandoned as a diaphoretic 
in the presence of an eclamptic attack is no good reason for prohibiting its 
use in this, the pre-eclamptic state, in the absence of pronounced cardiac 
disease, and the writer advocates its use for its diaphoretic and diuretic 
actions. 

Finally, when exercise cannot be taken and an abundant supply of 
fresh air is wanting, oxygen inhalations will prove of service. Some 
preparation of iron will also be called for, as the tincture of the chloride, 
or Basham's mixture. 

This, then, is the general hygienic and medicinal treatment of the pre- 
eclamptic state. No hard and fast rule can be laid down. Every case 
must be treated on its merits. In one a restricted diet and mild stimu- 
lation of the renal and intestinal functions is sufficient, and the patient 
may be allowed to be about, and even exercise in the open air, her skin 
being protected from sudden changes by being incased in wool or flannel. 
Other more pronounced cases of eliminative insufficiency must be kept 
absolutely quiet in bed upon an exclusive milk diet, and the stimulation 
of all the eliminative organs must be resorted to, to remove the symp- 
toms of impending eclampsia. 

But it must be kept ever before us that the hygienic and medicinal 
treatment is only of secondary importance to the milk diet, and that the 
latter is the foundation of the preventive treatment of puerperal eclamp- 
sia. Given a case in which, in spite of an exclusive milk diet and the 
vigorous stimulation of the five excretory outlets already mentioned, the 
symptoms and signs of the pre-eclamptic condition continue or at any 
time become urgent, the indication is to induce abortion or premature 
labor artificially. 

It is difficult to undersand the position of those authorities (notably of 
the British school of midwifery) who advise against inducing labor in 
the presence of urgent symptoms of the pre-eclamptic state. 



526 PATHOLOGY OF LABOR 

The arguments thai by the methods usually in vogue induced labor 
increases reflex excitability and precipitates convulsions; that by the same 
method-, because of the time necessary to remove the barrier of the cer- 
vix, the patient's fate is sealed before the delivery is effected; and, more- 
over, that the onsel of labor increases the danger to the patient, are good 
ones and demand attention. 

In answer, it may he said that methods of terminating the pregnancy 
recommended here need not increase reflex excitability, and, if per- 
chance they do, the excitability is readily controlled for the time neces- 
sary to accomplish our ends; that the time necessary is, in most cases, 
very short; and, finally, that to-day the onset of labor and the termina- 
tion of pregnancy may be practically brought about at one and the 
same time, and there is thus no prolonged or tedious labor to read 
unfavorably upou the patient. 

The objection raised by Byers (International Congress of Obstetrics 
and Gynecology, Geneva, September, 1896) that induced labor, because 
of the necessary manipulation, increases the risk of sepsis, should not 
deter the modern obstetrician from performing the operation when he 
knows that he is surgically clean. 

Charles, of the Liege Maternity, reported, at the International Con- 
gress of Obstetrics and Gynecology in 1896, in favor of induced labor 
when treatment fails or the symptoms become urgent in the pre-eclamptic 
state. His statistical table shows that every mother recovered and 75 
per cent, of the children were saved. 

The writer recommends a rapid manual dilatation of the os in these 
cases, but only after the cervical canal is in a condition favorable for its 
safe performance. Moreover, he would insist upon a complete dilatation 
of the os before delivery is undertaken. 

(6) The Curative Treatment. In the presence of an eclamptic 
attack we face a desperate condition. The latest statistics from various 
parts of the world still place the maternal mortality at from 25 to 35 per 
cent. As long as the pathology of eclampsia remains obscure there can 
be no rational curative treatment of the condition. Experience does not 
permit of recommending any single treatment. Many subjects recover, 
no matter what the treatment, many die in spite of treatment, and others 
do well without any treatment at all. No single treatment can be advo- 
cated; each case must be managed according to the indications present. 
Not a single but a combined treatment promises best for saving the lives 
of mother and child in the event of an eclamptic seizure. For this 
combined treatment three indications are offered, as follows : 

1. Control the convulsions. 

2. Empty the uterus under deep ancesthesia by some method that is rapid 
and that will cause as little injury to the patient as possible. 

3. Eliminate the poison or poisons which we presume cause the convul- 
sions. 

Although these indications are named in the order of their importance, 
still they may all be carried out at the same time. In another class of 
cases we fulfil the first and third, and wait for a suitable moment to carry 
out the second. The third indication — elimination — should really go 
hand-in-hand with the first two and be put into action at one and the 
same time with them. 



ECLAMPSIA. 527 

Control the convulsions. The four medicinal means most certain and 
safe as antieclamptics are chloroform, morphine (hypodermatically), verat- 
rnni viride, and chloral hydrate, the latter alone or combined with sodium 
bromide. 

The writer's preference is for chloroform, veratrum viride, and chloral, 
in the order named. Until three years ago he used morphine freely in 
eclampsia, but has since abandoned its use almost entirely, as it appar- 
ently prolongs the post-eclamptic stupor and increases the tendency to 
death during coma by interfering with the eliminative processes. 

Chloroform is of all agents the most reliable for immediate control of 
the convulsive seizures. 

Second only to chloroform in value is veratrum viride. Provided the 
pulse be strong as well as rapid, it is the most certain means at our com- 
mand for temporarily, and even permanently, controlling the convul- 
sions. When the pulse is weak morphine hypodermatically, chloroform 
by inhalation, and chloral by rectum, with stimulation, if necessary, may 
be substituted. 

Veratrum viride reduces the pulse-rate, and convulsions are practi- 
cally unknown with a pulse-rate of 60 or under; it reduces the tem- 
perature; it relaxes and renders more yielding the rigidity of the cervical 
rings; it causes prompt diaphoresis and diuresis, so that it aids not only 
in the fulfilment of our first indication, the control of the convulsions, 
but in the third, the elimination of an unknown poison as well. 

From ten to twenty minims of the fluid extract of veratrum viride, 
given subcutaneously, should, as a rule, be the initial dose. Ten minims 
more may be given in the same manner every half-hour till the pulse 
remains below sixty to the minute. The patient should be kept in a 
recumbent position while under the influence of the veratrum. Tumult- 
uous action of the heart is likely to supervene on assuming the erect 
position. Vomiting and collapse, should they ensue, are readily con- 
trolled by whiskey or by morphine. 

The last resort for controlling the convulsions is the prompt evacua- 
tion of the uterus. It may be added, however, that cold applications, 
such as ice-bags to the back of the head and neck, have a decided effect 
in controlling and in warding off convulsive attacks. 

Empty the uterus under deep anaesthesia by some method that is rapid 
and that will cause as little injury to the woman as possible. Those who 
follow the teachings of Charpentier, of France, and Winckel, of Ger- 
many — namely, that the uterus in eclampsia should be left alone except 
after full dilatation of the os, as the irritation of inducing labor or arti- 
ficially dilating a cervix precipitates convulsive attacks — will, doubtless, 
see many cases lost that could by prompt and intelligent measures be 
saved. It would appear from careful observation that the danger is 
practically over in some 90 per cent, of cases the moment the uterus is 
emptied, if accomplished early in the attack. Not that by this means 
the convulsions always cease, but they become less dangerous, and the 
case becomes one of post-partum eclampsia, in which the mortality, as we 
have stated, is only 7 per cent. 

Although one can scarcely find an authority to-day who absolutely 
rejects local interference in the presence of ante-partum or intra-partum 
eclampsia, yet authorities differ widely as to the extent to which such in- 



528 PATHOLOGY OF LABOR. 

terference Bball be carried. Charpentier, in 1892, as the result of an ex- 
haustive analysis of four hundred and fifty-four cases of eclampsia, and 
again in L896, as the result of further observation, practically arrives at 
the same conclusion, namely: 

1. That labor should be waited for and terminated naturally whenever 
possible. 

2. That induced labor should be reserved for exceptional cases in 
which medical treatment has entirely failed. 

3. That interference should be delayed until the cervix is dilated or 
dilatable, BO as to avoid danger to the mother; that in eclampsia Csesa- 
rean section, manual dilatation of the cervix, and especially deep incisions 
of the cervix are absolutely unjustifiable. 

On the other hand, it would appear from the literature of the last five 
years, and from the reports of the International Congress at Geneva, 
September, 1896, that the weight of medical opinion is in favor of 
emptying the uterus in as short a time as possible in instances of eclamp- 
sia, whether the attack occurs before or during labor, although there is 
a wide range of opinion as to the means to be employed. In the second 
stage of labor, after dilatation has been secured, all authorities are agreed 
that the immediate emptying of the uterus is indicated and is to be 
performed promptly; the indication under such circumstances is readily 
carried out without additional danger to mother or child. In pregnancy 
and the first stage of labor the undilated cervix is the barrier to imme- 
diate delivery, and it is here that obstetricians differ so widely as to the 
best method of procedure. An expectant or palliative treatment means 
almost certain loss of the child, and something like one-third of the 
mothers are lost. On the other hand, the child is saved and the mother 
is practically safe, as far as the eclampsia is concerned, if the uterus is 
immediately emptied by appropriate surgical means. 

During pregnancy and the early part of labor four procedures are 
offered for rapidly emptying the uterus, viz. : 

1. Cesarean section. 

2. Mechanical dilatation of the cervix (various methods). 

3. Deep incisions which at once completely remove the barrier of the 
cervix. 

4. Combined mechanical dilatation and deep cervical incision. 

The first method, Cesarean section, for the relief of eclampsia still 
carries with it a high mortality (36.26 per cent., according to Charpen- 
tier's figures); moreover, there are many objections to its employment, 
as the uterine atony and hemorrhage, the irritation of the uterine and 
abdominal scars and of the curative peritonitis about the uterine sutures, 
all of which are to be avoided as exciting causes of subsequent eclamptic 
seizures. 

The second method, the mechanical dilatation of the cervix and the 
immediate extraction of the foetus, appears to be the popular method of 
the day. Properly performed the method is safe and efficient. Before 
dilatation is well advanced, however, from forty minutes to an- hour and 
a half is necessary safely to carry it out, and certain conditions of the 
cervix, even in this time, refuse to yield to manual dilatation or result in 
lacerations into the lower uterine segment. 

The third method of delivery, by deep cervical incision, offers a sur- 



ECLAMPSIA. 



529 



gical means for emptying the uterus in from five to ten minutes, pro- 
vided the supravaginal portion of the cervix has disappeared or is made 
to disappear by appropriate means. 

The fourth or combined method is a combination of the second and 
third methods, and is applicable to cases in which the supravaginal por- 
tion of the cervix is still present and rapid emptying of the uterus is 
demanded. Here mechanical dilatation of the os until the internal os 
has been caused to disappear is made use of, and the dilatation then in 
an instant completed by the incisions. 

The third method and its modification, the fourth, are comparatively 
new, and we have few statistics as to the results of the operation. A 
rapid manual dilatation of the os and subsequent extraction of the foetus 
will fulfil the indications in most cases; but unless this can be intelli- 
gently carried out, with a due appreciation of the mechanism of dilata- 
tion, especially in primiparae, a purely expectant treatment will give 
better results. Unfortunately, puerperal eclampsia is four times more 
frequent in primiparaB than in multipara?, although, on the other hand, 
the mortality is greater in the latter. 



Fig. 337. 




IN. OS. 



S.V.C 



EX. OS. 



Cervix in latter part of gestation or at 'beginning of labor. Vaginal and supravaginal portions 

of cervix unchanged. (From Edgae.) 
v. Cuff of vagina, ex. os. External os and infravaginal portion of the cervix, c.v.j. Cervico- 
vaginal junction, s.v.c. Supravaginal portion of cervix, in. os. Internal os. L. u. s. Lower uterine 
segment. 



The cervix uteri is composed of constricting and dilating muscle, and, 
while it is true that the first convulsions usually induce labor, still the 
resulting asphyxia exerts a marked constricting action upon the body of 
the uterus and cervix, which is especially marked at the internal ring 
of the os. Therefore, any method of rapid manual dilatation of the os 
that is undertaken before the internal os has been made, partially at least, 
to disappear is attended with great danger of uterine rupture (Figs. 337, 
338). This is especially true in priuriparae, in whom the supravaginal 
portion of the cervix obtains late in pregnancy and even up to the begin- 

34 



530 



PATHOLOGY OF LA Hoi:. 



nine of labor (Fig. 337). We believe a warning should be sounded 
against the careless undertaking of rapid manual dilatations of the os, 



Fig. 388. 




IN. OS 



Lower uterine segment during labor. (From Edgar.) 
v. Cuff of vagina, ex. os. External os, infravaginal portion of cervix has disappeared, c. v. J. Cer- 
vico-vaginal junction, s. v. c. Supravaginal cervix, small portion only remaining, in. os. Internal 
os. L. u. s. Lower uterine segment. 

particularly in eclampsia. Uterine rupture and death have been the 
outcome. Moreover, undue shock has resulted from the dragging of a 

Fig. 339. 




IN. OS. 



EX. OS. 



Lower uterine segment during labor. Os uteri in progress of dilatation. Supravaginal and infra- 
vaginal portions of the cervix have disappeared. Os admits one finger. (From Edgar.) 
v. Cuff of vagina, ex. os. External os. in. os. Internal os. u. v. J. Utero- vaginal junction. 
L. D. s. Lower uterine segment. 

foetus through an imperfectly dilated os ? to say nothiug of the loss of 
the child. 

In placenta prsevia the hemorrhage and the resulting anemia of the 






ECLAMPSIA. 



531 



lower uterine segment and cervix render these parts more readily dilat- 
able. In eclampsia the reverse obtains, as has been already hinted. 
Hence it is that in eclampsia in instances in which the internal ring of 
the os has been drawn up into the body of the uterus (Figs. 338, 339), 
and the external ring remains rigid and tense, particularly in primiparse, 
and there is urgent need of rapidly terminating the labor, we prefer four 
clean incisions extending from the edge of the os to the utero- vaginal 
junction, in order to save the patient from the greater dangers of rapid 
manual dilatation. 

Fig. 340. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os two-thirds dilated. Entire effacement of the internal os. Compare Fig. 339. 

In the second place, a warning is not out of place against the prema- 
ture extraction of the foetus before full dilatation has been secured and 
the external ring of the os paralyzed. Premature extraction, under such 
circumstances, has, to the writer's knowledge, resulted in many unneces- 
sary and dangerous lacerations of the lower uterine segment and an 
increase of the mortality for the child and mother. 

Elimination of the poison or poisons which are presumed to cause the 
convulsions. To eliminate toxic materials from the blood and tissues 
the following measures may be relied on. It is essential, however, to 
rely not upon one but upon all the eliminative organs of the body, 
and that the fulfilment of this third indication in the treatment of 
eclampsia should go hand-in-hand w T ith the two already mentioned. 



582 PATHOLOGY OF LABOR. 

T.> this end catharsis must be Becured as early and as promptly as possi- 
ble by the administrate I croton oil, compound jalap powder, or calo- 
mel, followed by salines and high enemata of sulphate of magnesium. 

In the coma or po8t-eclamptic stupor of the condition the writer has 

relied mainly upon the repeated administration of concentrated solutions 
of Bulphateof magnesium or Villacabras water, by means of a long rectal 
tube nigh up in the descending colon. The hypodermatic administration 
of magnesium sulphate has been found too slow and uncertain to be of 
any use. Diuresis is obtained by dry or wet cups over the kidneys, 
followed by hot fomentations. The value of glonoin as a diuretic and 
antieolamptic, the latter by reducing the arterial tension, cannot be over- 
estimated. Second only in value to glonoin is veratrum viride. It is 
to be given at this time for the same reasons and for the same results as 
when it was administered in the pre-eclamptic condition. Diaphoresis 
is encouraged by means of the hot-air bath or the hot pack, the writer's 
preference being for the former. Pilocarpine as a diaphoretic in the 

Fig. 341. 




Dangers of a rapid breech extraction through an imperfectly dilated os. External os not fully 
dilated or paralyzed. Traction on the legs results in extension of the head and both arms. (From 
Edgar.) 

presence of an eclamptic attack should be utterly rejected, because of the 
danger of oedema of the lungs and glottis which it may produce. These 
conditions may follow promptly upon its administration. The drawing 
off of large quantities of toxic liquids in the form of blood or serum, 
by means of venesection, catharsis, diaphoresis, diuresis, followed by the 
replacement of the same by intravenous, stomachic, rectal, or hypodermatic 
means, causing a washing or disintoxication of the blood and tissues, as 
it were, has thus far proved of doubtful value. On the other hand, the 
prolonged irrigation of the lower bowel with either normal saline or 
sterile water, by means of a long single or return-flow tube, has given 
most excellent results. In instances of collapse, with the small compres- 
sible pulse, the introduction into the blood of a normal saline solution is 
of the same value here as in collapse under other circumstances. As a 
diuretic the frequent (hourly) subcutaneous injection of ether has been 
highly praised by some. As a general stimulant, to assist in the elimi- 



ECLAMPSIA. 



533 



u.v 




Fig. 342. 

L.U.S. 




EX. OS, 



V. 



Lower uterine segment at completion of first stage of labor. Os uteri completely dilated. 

(From Edgar.) 
v. Cuff of vagina, ex.so. Border of external os, scarcely perceptible, u. v. J. Utero- vaginal junction. 

l. u. s. Lower uterine segment. 

Fig. 343. 







Bimanual dilatation of tbe parturient os. (From Edgar.) 

Os is fully dilated and is being stretched and paralyzed, to prevent subsequent accidents to the 

after-coming head during the extraction of the foetus. Compare Fig. 337. 



534 



PATHOLOGY OF LABOR. 



cation from the lungs and to prolong life in the post-eclamptic stupor or 
coma, the free administration of oxygen Is of the greatest value. Fur- 
ther, alcohol will often be needed as a stimulant during and after an 
eclamptic attack, and strychnine in the post-partum state and in the face 
of threatened collapse — although for physiological reasons it would seem 
to he contraindicated — lias served us well. 

Fig. R44. 




) 

\ 



Instrumental dilatation of the parturient os, preparatory to further manual dilatation, gauze packing, 
and the introduction of bougies or cervical dilators for the induction of labor. (From Edgar.) 

Finally, although no one has been or is a firmer believer than the 
writer in the efficacy of a prompt removal of foetal metabolism and of 
irritation for not only the control but the cure of the eclamptic condition, 
still he begs to enter a protest, first, against the careless use of the term 



ECLAMPSIA. 



535 



accouchement force as applied to the rapid, scientific, and intelligent 
emptying of the uterus; and, secondly, to the easy confidence with which 
this accouchement force has been recommended as the best, if not the only, 
means at our command for the control of eclamptic seizures, without 
attaching sufficient importance to the condition of the cervical barrier. 
By accouchement force are understood to-day three operations, namely, 
(1) the complete instrumental or manual dilatation of the cervical canal, 
followed by (2) either combined or direct version, or the application of 
the forceps, and (3) the immediate extraction of the child. 



Fig. 345. 




Digital dilatation of the parturient os. (From Edgar.) 
Os admits one ringer. Vaginal and supravaginal portions of the cervix present. Compare Fig. 337. 

The accouchement force of the older writers upon obstetrics was often 
quite another and more serious operation, for the condition of the 
cervical canal was frequently lost sight of, and it too often meant (1) 
the plunging of the hand or the application of the forceps through a 
cervical canal imperfectly dilated, and (2) the immediate extraction of 
the foetus through this constricted os. That the latter definition of the 



536 



PATHOLOGY OF LABOR 



term still obtains seems proven by the frequency of accidents in the 
extraction of the foetus thai arc constantly being brought to light. 

Our maternity hospitals arc repeatedly in receipt of ambulance or 
emergency cases due to the neglect on the part of the operator to fulfil 
the first condition of the operation, namely, complete dilatation. It is 
no uncommon event for emergency cases to be brought to our hospitals 

Fig. 846. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os admits two fingers. Vaginal and supravaginal portions of the cervix present, 
shortening of the cervical canal. Compare Fig. 337. 



Commencing 



with a podalic version or extraction partially completed because of the 
operation being attempted in the presence of a partially dilated os (Figs. 
340, 341); moreover, for uterine rupture to occur, due to the same cause. 
In Fig. 341 is represented the outcome of a premature extraction 
through an imperfectly dilated os. With such a complication — a rigid, 



ECLAMPSIA. 



537 



imperfectly dilated external os, grasping the foetus tightly under the 
armpits — the loosening of the arms, the dragging of these, and subse- 
quently the head through the os will take considerable time, and not only 
forfeit the child's life but subject the lower uterine segment to dangerous, 
if not fatal, rupture. Our plea in these cases is not alone for complete 
dilatation or disappearance of the external ring, as seen in Fig. 342, but 
further, for a paralysis of the ring, as we see it performed in Fig. 343, 



Fro. 347. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os admits three fingers. Supravaginal portion of the cervix disappearing. 



so that the dangers of the extractiou, whether by forceps or version, may 
be reduced to a minimum for both mother and child. 

The limits of the present article forbid entering upon the arguments 
for or against any particular variety of rapid manual or instrumental 
dilatation of the parturient os, further than to state that the writer's pref- 



538 



PATHOLOGY OF LAP,' HI. 



erenoe is for a rapid bimanual method, as shown in tlie illustrations, since 
be has given this method an abundant trial over a period of several years, 
and it has proved mosi satisfactory. 

The bimanual method is to be preferred to other digital and instru- 
mental methods, because (1) the membranes are preserved throughout the 
operation or until full dilatation is obtained; (2) there is no interference 
with the original presentation and position; (3) the sense of touch of the 
operator's fingers is unimpaired; (4) there is no constriction of the opera- 
tor's hands; (6) the amount of force exerted upon the external ring can 
be better estimated, and hence there is less likelihood of lacerations 
occurring; (0) in placenta praevia there is less preliminary separation of 
the placenta by this method than by any other; (7) by no other method 
with which we are acquainted can not only complete dilatation, but also 



Fig 348. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os one-half dilated. Lateral position of the hands. 



complete paralysis of the parturient os, be so quickly and safely obtained 
(Figs. 340, 343). 

Again, the writer begs leave to protest against the undertaking of a 
rapid manual dilatation of the os (namely, the entire dilatation completed 
within an hour) before the cervix has become, at least slightly, relaxed 
by uterine action, and is already somewhat yielding. A rigid cervix, in 
the condition seen in Fig. 337, should receive preliminary treatment, by 
means of a cervical dilator of gauze or a hydrostatic bag, that will set 
up some uterine action and render the rings of the os yielding enough 
to make rapid dilatation a safe operation. In the presence of even a 
minimum amount of uterine action, or with a softening, yielding, and 
relaxing os, although the anatomical conditions shown by Fig. 337 



ECLAMPSIA. 539 

may obtain, one may still undertake rapid manual dilatation and pro- 
duce complete paralysis of the cervix within an hour, as seen in Fig. 
343. Far better a purely expectant treatment, as regards emptying the 
uterus, than the attempt rapidly to overcome a rigid os by manual meth- 
ods, the supravaginal portion of the cervix being present. The writer 
has known complete uterine rupture to result from such an undertaking, 
the maternal intestines prolapsing between the fingers of the operator. 
Fortunately for the eclamptic woman, the frequency of the attack 
increases proportionately with the progress of gestation, and, it may be 
added, with the increase of foetal metabolsim. Hence, the attack is more 

Fig. 349. 



( 






/ 



< 



) 

j 



Bimanual dilatation of the parturient os. (From Edgar.) 
Os two-thirds dilated. Entire effacement of the internal os. Compare Fig. 339. 

frequent in the latter part of pregnancy and in labor, when we can more 
readily and safely apply our surgical principle of treatment, namely, an 
early and rapid evacuation of the uterus. 

Unfortunately, the attack is four times more frequent in primiparse 
than in multipara?, and in the former the presence of the supravaginal 
portion of the cervix late in pregnancy, and of an unyielding and unre- 
laxed os, compels us to make use of preliminary and temporizing means 
before we can safely perform a rapid dilatation of the os and subsequent 
extraction of the foetus. It is in such cases, and at such a critical time, 



640 



PA VHOLOQY OF LABOR. 



when one is waiting for the measures preparatory to a rapid dilatation 
and emptying of the uterus to act, and to give us at least a yielding and 
relaxed cervical canal, if not a partial disappearance of the internal os, 
that the writer has found veratrum viride most valuable and life-saving, 

by reason of the various actions of the <\vwj: already mentioned. 

In order to render the preferred method of rapid dilatation of the 
pregnant or parturient os more graphic, and also that the sequence of the 



Fig. 350. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os is fully dilated and is being stretched and paralyzed to prevent subsequent accidents to the after- 
coming head during the extraction of the foetus. Compare Fig. 342. 

different steps of the operation may more clearly be set forth than they 
are in the limited number of illustrations in the article upon puerperal 
eclampsia, the nine illustrations 1 (Figs. 344 to 352) are introduced. 

The illustrations demonstrate the different steps in a rapid dilatation 
of the os uteri, commencing with instrumental dilatation (Fig. 344), at 



1 These illustrations are from photographs of composition and plaster models, and have already 
appeared in a series of articles on " Methods and Aids in Obstetric Teaching," published in the New 
York Medical Journal, November 14, 21, 28, and December 5, 1896. 



ECLAMPSIA. 

Fig. 351. 



541 




Bimanual dilatation of the parturient os. (From Edgar.) 
Internal view, showing the position of the fingers. Os admits three fingers readily. Internal os 
still present. No encroachment of the fingers upon the cavity of the lower uterine segment. Com- 
pare Fig. 352. 

Fig. 352. 




Bimanual dilatation of the parturient os. (From Edgar.) 
External view, after a photograph of the operation as performed at the Emergency Hospital, 

New York. 



542 PATHOLOGY OF LABOR 

a time when the internal oa 1ms partially disappeared, and the cervical 
canal is Bomewbaf relaxed and yielding, continuing with digital dilata- 
tion, and finally ending with bimanual Btretching and paralyzing of the 

fully dilated parturient OS uteri (Fig. 350). In Fig. 351 is shown the 
position of the fingers in the bimanual method of cervical dilatation, as 
seen from the uterine cavity; and Fig. 352 is added, which is* after an 
actual photograph of the operation of manual dilatation of the par- 
turient os, taken from nature at the Emergency Hospital (Bellevue Hos- 
pital service), in order that the position of the patient and the position 
of the operator's hands during the operation may be clearly seen. 



CHAPTER XXIV. 

DIABETES.— CARDIAC DISEASE. 

Diabetes rnellitus is a dangerous complication of labor and the puer- 
peral state, as it is well known to be of surgical operations. Fortu- 
nately, it is rarely met with in obstetric practice. The disease may ante- 
date the pregnancy or may develop in the course of it. That it may 
occur as a result of pregnancy would seem possible from the fact that in 
exceptional instances the disorder appears only during gestation, subsid- 
ing after delivery. It may be present in one or more and absent in 
subsequent pregnancies. A transient glycosuria is met with in a small 
percentage of pregnant women, but is most frequently a lactosuria. 
Lanz administered chemically pure grape-sugar to several women imme- 
diately after labor in quantities of 100 grammes to each. The urine 
was drawn by catheter just before the ingestion of the sugar and at the 
end of two, four, and six hours subsequently. In 30 per cent, of the 
urines grape-sugar was found. These observations go to prove that 
sugar metabolism is diminished in the first few hours or days of the 
puerperium and probably in the later weeks of pregnancy. 

Frequency. There are no sufficient data on which to base a definite 
statement of the frequency of diabetes as a complication of labor. 
Statistics show, however, that the disease is associated with pregnancy 
in less than 1 per cent, of diabetic women. Women suffering from 
diabetes are usually sterile. 

Diagnosis. The essential phenomena of the disease are the same in 
pregnancy as in other patients. The diagnostic evidence is to be sought 
chiefly in the urine. The test for sugar should be included in the usual 
urinary examinations during pregnancy, yet lactosuria must not be mis- 
taken as evidence of diabetes. Lactose is sometimes present in the 
urine during the later weeks of gestation in healthy women. The liquor 
amnii is usually excessive in amount, and it contains sugar and some- 
times acetone. 

Prognosis. Pregnancy in women previously diabetic terminates in 
abortion in about 33 per cent, of cases. The prognosis for the mother 
is especially grave when the disease is aggravated by pregnancy and 
resists treatment. The danger to life is greatest in the later months. 
Fifty per cent, of the mothers suffering from this disease die soon after 
labor. Of 22 cases collected by Matthews Duncan, 4 were fatal after 
delivery, within the puerperal period, death being due to collapse and 
coma. The mortality for the children born of diabetic women exceeds 
40 per cent. It very frequently happens that the foetus dies soon after 
becoming viable. Sometimes the child is dropsical. In one case the 
child had glycosuria. In view of these facts a woman the subject of 
diabetes ought not to become pregnant. 

Treatment. The medicinal and dietetic treatment of diabetes in the 

(543) 



54 1 PATHOLOG V OF LABOR 

pregnant patient does not differ from thai usually adopted under other 
circumstances. If the Bymptoms arc pronounced, and especially if they 
arc not relieved by treatment, the pregnancy should be terminated. 

Cardiac Disease. 

The physiological hypertrophy of the heart in pregnant women testifies 
to the increased work put upon it during gestation. Pre-existing cardiac 
lesions are liable to be aggravated by pregnancy, and in advanced disease 

the heart may seriously he crippled in the later months. The circulatory 
disturbance usually begins near midpregnancy. The danger is especially 

great under the added strain of labor, and it culminates in the third 
Btage,when a large vol nine of blood is abruptly thrown upon the venous 
side by the uterine retraction, causing dilatation of the right heart. Yet 
in a considerable proportion of cases the heart, even though damaged, 
proves equal to the increased demand upon it, and apparently sustains 
little or no added injury. 

The mitral valve, either alone or with others, is oftenest affected. Of 
92 cases of valvular disease in pregnancy collected by Porak, the mitral 
valve alone was diseased in 57; both mitral and aortic valves were 
involved in 22. In 22 there was mitral insufficiency, in 13 mitral 
stenosis, and in 22 both conditions were present; in 13 the aortic valve 
only was diseased, insufficiency existing in 9, stenosis in 2, and the 
double lesion being present in 2. 

Prognosis. Most fatal of the valvular lesions in pregnancy is mitral 
stenosis. Eight of the thirteen cases recorded by Porak terminated fatally. 
McDonald reports fourteen cases with nine deaths. In double mitral 
lesions the mortality is still greater. The death-rate in aortic disease is 
from 23 to 25 per cent., while in mitral insufficiency, the best borne of 
all the valvular affections, the proportion of deaths is not far from 13 
per cent. 

The period of greatest danger is the close of the second stage of labor. 
During the pains of this stage the venous circulation is impeded by the 
prolonged and violent expulsive efforts. The right heart is dilated, as 
indicated by the swollen veins of the neck and the cyanotic hue of the 
face. At the moment of expulsion or directly after, as the uterine sinuses 
are emptied, an additional volume of blood is thrown upon the already 
overloaded right heart, often with fatal effect. Obviously the prognosis 
must depend largely on the condition of the myocardium. With full 
compensation the patient may pass safely through pregnancy aud labor. 
In advanced cardiac disease the prognosis is always bad. In marked 
failure of compensation, with dilatation of the right heart and much 
pulmonary congestion or oedema and albuminuria, it is extremely grave. 
Owing to the increased labor imposed upon the heart in the later months 
of pregnancy, existing cardiac disease is, as a rule, permanently aggra- 
vated by child-bearing. 

All forms of heart disease predispose to abortion. In a large propor- 
tion of cases the pregnancy terminates prematurely. The immediate 
cause of the abortion may be excess of carbon dioxide in the blood or 
placental apoplexies. 

The tendency to post-partum hemorrhage is increased by the circula- 



CARDIAC DISEASE. 545 

tory obstruction, yet moderate bleeding at the close of labor is conserva- 
tive by relieving the venous engorgement. 

Symptoms. The symptoms of valvular disease vary according to the 
extent of the lesion, the valves affected, and the amount of compensatory 
hypertrophy which is present. They do not differ essentially from the 
usual manifestations of similar lesions under other circumstances. Pal- 
pitation, dyspnoea, and more or less precordial distress are common in 
the later months of pregnancy, even in the milder forms of valvular 
disease. 

Dilatation of the right heart is attended with visible pulsation of the 
veins of the neck and with epigastric pulsation. The first sound is weak 
and the area of dulness is increased. Pulmonary congestion or oedema 
and venous stasis in other viscera frequently develop, especially during 
labor. 

Treatment. Peter says a woman with heart disease should not marry; 
if she is married she should not become pregnant; if she has passed 
through one or two pregnancies safely she should not again become 
pregnant; and, finally, if she gives birth to a child, she should not be 
allowed to nurse it. Peter's dictum, however, is too sweeping. It 
should be limited rather to the grave forms of valvular defect and to 
incompetence of the heart-muscle. 

:The hygienic management of cardiac disease in pregnancy is impor- 
tant, and consists in the avoidance of undue exertion, physical or mental, 
of sudden chilling of the surface of the body, and in the removal, if 
possible, of all sources of nervous disturbance. 

The medicinal treatment either during pregnancy or labor is for the 
most part symptomatic. Iron, arsenic, or strychnine are frequently use- 
ful as tonic measures. For cardiac supports strophanthus in 5-minim 
doses of the tincture several times daily, or the tincture of digitalis, 5 to 
10 minims three times daily, may be used, or digitaline may be given in 
Tiro" t° ^V grain doses. Trinitrine, by preventing the contraction of the 
arterioles caused by digitalis, is a valuable auxiliary to the latter drug. 

The obstetric management of serious cardiac disease will often tax the 
physician's skill and judgment. When the woman is in imminent peril 
the artificial interruption of pregnancy is demanded. Yet, when the con- 
ditions are bad enough to justify interference, even a premature labor is 
attended with great danger. Kaltenback regards uncompensated valvular 
disease as a positive indication for the induction of labor. Fehling 
would terminate the pregnancy when, in addition to the non-compensa- 
tion, there is chronic bronchitis with marked emphysema. In the pres- 
ence of such pulmonary congestion and oedema, with extensive visceral 
complications, general anasarca or ascites, and extreme dyspnoea, and 
especially if the symptoms become more pronounced notwithstanding 
treatment, the uterus should be emptied. Winckel, on the other hand, 
speaks discouragingly of the results of premature delivery. 

The indications after labor has begun are to deliver the patient with 
as little exertion on her part as possible. Chlororoform should be used 
to diminish violent effort and to limit shock. After sufficient relaxation 
forceps should be employed. Should the dilatation be slow, it may be 
hastened by artificial means; manual dilatation, or, if the emergency 
requires, Diirhssen's incisions should be practised. Meantime, the heart 

35 



5 1.; PATHOLOGY OF LABOR. 

Bhould be braced with one or more of the usual cardiac supports — stro- 
phanthus, Bpartein, digitalis, trinitrine, and caffeine. These agents act most 
promptly and efficiently if given by the hypodermic method. Sudden 
asystole at the end of the Becond stage is best met with inhalation of 
nitrite of amy] and with hypodermics of ether or strychnine. When 
these measures fail, from 10 to 16 ounces of blood should he taken from 
the arm. Ergo! should be proscribed, since it contracts the arterioles 
and increases the circulatory obstruction; moreover, it limits the blood 
loss from the uterus. Moderate bleeding after delivery is beneficial. 
When not sufficiently free it should be favored by the use of douches of 
warm sterile water, at a temperature not exceeding 40° C. (105° F.). 
If during the labor the patient suddenly expires, the child being viable, 
accouchement force, or, if need be. Caesarean section, should at once be 
performed, in the hope of saving the child. 



PART VII. 

PATHOLOGY OF THE PUERPERIUM. 



CHAPTER XXV. 

ANOMALIES AND DISEASES OF THE BEEASTS AND NIPPLES. 

Normal Data. The reader will recall that each mamma empties its 
secretion through the nipple by means of about twenty ducts in direct 
communication with the mammary acini. These ducts are lined with 
cuboidal epithelium. 

The acini are composed of saccular dilatations of the terminal ends of 
the smallest ducts, and possess a membrana propria lined with character- 
istic secretory epithelium. White, fibrous and adipose tissues surround 
the acini in varying proportions, according to age and the individual. 
Like all other active glands, the mammae are rich in bloodvessels, lym- 
phatics, and nerves. 

The blood-supply is peculiar in that the ducts are surrounded by a 
vascular plexus, instead of parallel vessels inosculating with one another 
as in the voluntary muscles. 

The nerve-endings have never been conclusively traced; but they 
doubtless terminate in the parenchymatous elements. 

The lymphatics communicate ultimately with a single large channel 
extending to the axilla. 

The breasts reach fullest development during pregnancy. At this time 
the glandular epithelia become enlarged and filled with milk globules. 

Anomalies. 

Supernumerary nipples and breasts, defective development of the 
nipples, and absence of one or both breasts are occasionally met with. 
These anomalies are of obstetric interest only in so far as they may affect 
the woman's ability to nurse her child. 

Defects of the nipples are especially important, as they may interfere 
with nursing. Both congenital and acquired deformities are common. 
The nipples may be primarily small, sunken, or inverted, or imper- 
fectly developed from pressure of faulty clothing. 

The nipple lesions of lactation are largely the result of defective devel- 
opment, and consequent difficulty in nursing. 

Sore Nipples. 

Nipple lesions of greater or less severity occur in nearly 50 per cent, 
of nursing women, and begin usually within the first few days after 
suckling is inaugurated, being due to maceration and abrasion of the 

(547) 



548 PATHOLOGY OF THE PUEBPEBIUM. 

cuticle by the infant. They are of clinical importance by virtue not 
only of the exquisite Buffering they may occasion during nursing, but 
especially of their etiological relation to mastitis. Mere erosions may 
soon heal and give rise to no further trouble. While they persist they 

arc often extremely painful, and they commonly lead to more serious 
Lesi »ns. 

Fissures occur at the base or top of the nipple. The latter run trans- 
versely to the axis of the breast. Ulcers not infrequently result, and 
when milk-ducts open into the base of an ulcer they are occluded as the 
nicer heals. 

Etiology. Defective development and deformities, by rendering nurs- 
ing difficult, frequently act to increase the injuries inflicted on the nipples 
during suckling. Needless maceration of the nipples by too prolonged 
and frequent nursing is often the cause of erosion and fissure. Soor or 
thrush in the child's mouth exposes the nipples to infection. Uncleanli- 
ness of the nipples in the later weeks of pregnancy, and especially during 
lactation, is a common source of septic invasion. 

Treatment. Prophylactic. Prevention should begin in the manage- 
ment of pregnancy. The presence of defective nipples should not escape 
the antepartum examinations. Teach the woman to draw them out daily 
during the last two or three months of pregnancy with clean fingers or 
by means of a suitable breast-pump. This practice not only tends to 
develop them but also prepares them to better withstand the mechanical 
violence of beginning nursing. The mother should be warned of the 
injury that may be done by tight clothing. 

For at least a month before labor special attention must be paid to the 
cleanliness of the parts. Daily bathing in warm water and a bland soap, 
or with a solution of borax — a tablespoonful to the pint of boiled water 
— is a valuable precaution. The use of agents for hardening the nipples 
is not advised. There is reason to doubt that bathing the nipples with 
alcoholic and other astringent solutions is a suitable preparation for nurs- 
ing. It is more than probable that hardening the skin predisposes it to 
cracking. It would seem more rational to keep the nipples as supple as 
possible. The application of fresh cocoa-butter or some equally bland 
emollient after the daily cleansing promotes this end. 

Dr. J. M. Mabbott praises the following treatment : Daily for a month 
or more before labor the patient anoints the nipples at night with lanolin, 
working it thoroughly into them by kneading them between the thumb 
and fingers. In the morning the nipples receive a prolonged scrubbing 
with a soft nail-brush and pure soap and water, care being taken not to 
abrade the skin surfaces. The nipples are then rinsed and dried. 

AVhen nursing begins the delicate cuticle of the mammilla may be broken 
and abraded, and during the post-partum month the septic exposure is 
especially increased by the contact of hands liable to be infected from 
the lochial discharges. The occurrence of thrush or of ophthalmia in 
the child obviously adds to the risk of infection. Hence the need of 
a cleanly management of the nipples during the first weeks of lactation. 
The avoidance of septic contact is clearly important. Bathing with a 
boric-acid lotion after each nursing is useful. A saturated aqueous 
solution is not too strong. Cleansing the infant's mouth with a similar 



ANOMALIES AND DISEASES OF THE BREASTS AND NIPPLES. 549 

wash, once or twice daily, is in the interest of both mother and child. 
Care must be taken not to abrade the buccal mucous membrane, lest 
the practice invite the trouble which it aims to prevent. More active 
antiseptics are more effectual, but they require greater care in use. The 
writer has employed with satisfaction a nipple dressing wet with a mer- 
curic iodide or chloride solution (1-5000 or 1-10,000). The mercurial 
must be rinsed off with boiled water or w T ith the boric-acid solution 
before nursing. 

To limit the injury done by maceration and bruising, a single nursing 
need not occupy more than ten or, at the most, twenty minutes, and 
regularity should be insisted upon. 

The cacao-butter or some other similar inunction may be employed 
with advantage after each nursing, the surfaces having first been cleansed 
as already detailed. 

Curative Treatment. Excoriations and slight fissures heal in most 
cases under proper and timely antiseptic treatment. An ointment of 
equal parts of sub nitrate of bismuth and castor oil may be used as ad- 
vised by Hirst. The writer has generally preferred to this a similar 
ointment made with the glycerite of starch. But the glycerin preparation 
may not always be well borne by the skin. The ointment should fre- 
quently be sterilized by heat. Before applying the parts are disinfected. 
A valuable agent for the latter purpose is the hydrogen dioxide. While 
a host of nipple lotions and other applications have been recommended 
in these affections, none is more rational or promises better results in 
ordinary cases than some simple but carefully executed antiseptic plan of 
treatment. 

Pain during nursing may be relieved to some extent by pencilling the 
nipple five or ten minutes before the child is put to the breast with a 1 
to 5 per cent, cocaine solution. The solution ought to be heated to the 
sterilizing point shortly before using. 

A 1 or 2 per cent, carbolic lotion applied in the same manner is some- 
times useful as an anaesthetic. The addition of one-tenth its volume of 
glycerin prolongs the action of the lotion and keeps the skin soft. 

After the application of drugs the nipples should always be cleansed 
before nursing. 

In excoriations and fissures that are not too sensitive and do not bleed 
readily, nursing through a nipple-shield may be tried. The shield pro- 
tects the nipple from the friction, and to some extent from the maceration 
of suckling. Unfortunately for this method, the child may not accept 
the substitute for the natural nipple. If artificial nipples are used, it is 
important that they be rendered aseptic by boiling for five minutes in 
water immediately before using and not handled with unclean fingers. 

Similar protection to the nipple lesions is afforded, though in a less 
degree, by coating the affected surfaces with a pellicle of compound 
tincture of benzoin. 

Deep and painful fissures may be treated with the solid stick of nitrate 
of silver. The entire raw surface should be touched. The lips of the 
fissure being well separated, the caustic point is drawn slowly through 
it. This is repeated, if required, in three or four days. Care must be 
taken that no excess of moisture is present, otherwise the dissolved silver 
salt may trickle over the surrounding surfaces and healthy structures 



550 PATHOLOGY OF THE PUEBPEBIUM. 

be injured. A serious objection to this treatment is the exquisite pain 
it causes. This may in great measure be prevented by firsl benumbing 

the part with a 1 per cent, cocaine solution. After the application of 
the caustic the nipple may be covered with a piece of lint well wet with 

the anaesthetic lotion. 

I tistead of the solid stick, two or three applications daily of an aqueous 

Solution of the nitrate of silver may he preferred. In the strength of 1 
or 2 percent, it causes little pain and frequently does good service. The 
affected nipple should be rested, if possible, for twenty-four hours or 
more. 

When other measures fail, suspension of nursing for one or two days 
sometimes succeeds. If both breasts are affected each may be rested on 
alternate days. 

It is very rarely that the nipple lesions are so rebellious to well-directed 
treatment as to necessitate the total abandonment of nursing. 

Mastitis. 

Mastitis occurs in 5 to 6 per cent, of nursing women, oftenest in prirn- 
ipara?, and may or may not terminate in suppuration. In the great 
majority of cases it begins within the post-partum month. 

Etiology. That the essential factor in mastitis is sepsis does not 
admit of discussion. Here, as elsewhere, the suppuration and the 
local morbid process which leads up to it are due to infection. Obvi- 
ously the offending organism may be any of the pus-producing germs. 
Most frequently found, according to Escherich, are the staphylococcus 
aureus and albus. The streptococcus of pus is next in order of frequency. 
The lochia is a prolific source of infectious material, which during child- 
bed is added to the usual septic exposures. 

The predisposing causes and the methods of infection are questions 
involved in some dispute. Impaired general health and local mechan- 
ical injuries, diminishing the resisting power, are obviously important 
predisposing factors in many cases. Contusions of the breast from blows 
or from bruising with the breast-pump may become the starting-point of 
mastitis. 

The influence of milk stasis, which is so large a factor in the popular 
belief, is differently estimated by obstetric writers. Olshausen denies that 
it causes inflammation. Roser holds that milk retention is a result, not 
a cause, some of the lactiferous ducts being occluded by inflammatory 
swelling of surrounding structures. Others think milk stasis may favor 
the growth of bacterial organisms. Possibly retention by damaging 
the delicate endothelium of the lacteal ducts in the engorged areas may 
become a factor in the septic invasion. Engorgement alone is not a 
competent cause. 

That the nipple lesions so common during early lactation hold a 
prominent place among the predisposing causes of infection does not 
admit of doubt. Fissures of the nipple and even the abrasions, which 
are almost invariably produced by the friction of the child's tongue and 
lips in the first weeks of lactation, expose the lymphatics directly to the 
entrance of septic organisms. 

That the morbific agent in a considerable proportion of cases enters 



ANOMALIES AND DISEASES OF THE BREASTS AND NIPPLES. 551 

by the lactiferous tubules is beyond question. It is well known that 
pathogenic germs may penetrate healthy mucous or serous surfaces. Fre- 
quently the way is made easy by the injury done by milk engorgement 
or by mechanical violence. That pyogenic bacteria which have gained 
access to the milk ducts from without may pass into the deep structures 
of the gland, even against the milk stream, cannot be doubted. Eecent 
observations have shown that staphylococci are frequently present in the 
milk of perfectly normal breasts. Palleski examined the milk of twenty- 
two healthy nursing women and found staphylococcus albus in ten. Sim- 
ilar observations have been made by other investigators. That mastitis 
occurs so infrequently, despite the frequent presence of the microbic causes 
of suppuration, must be explained by the fact that a favorable condition 
of the soil as well as the presence of the germ is necessary to bacterial 
growth. 

A possible source of mammary inflammation which is not often men- 
tioned by obstetric writers is infection through the blood channels. 
Karlinski declares that micro-organisms from the cavity of the uterus in 
process of involution may be found in the blood. Escherich affirms that 
staphylococci which have gained access to the blood through infection of 
the genital apparatus are excreted in the milk as well as by other chan- 
nels. In the milk of infected puerperse he found, without exception, 
staphylococcus aureus or albus. That infection of injured mammary 
tissues is possible from sepsis in remote organs is abundantly established 
by clinical observations and by the experiments of numerous observers 
on the localization of septic processes. Not alone direct injuries of 
the breast invite such localization, but there is reason to believe that 
general pathological conditions, even exposure to cold, may act in this 
manner. 

We must conclude that the infecting organisms may reach the gland 
structures through the lacteal ducts, the lymphatics, or the bloodvessels; 
that nipple lesions, milk stasis, contusions of the breast, impaired general 
health, probably chilling, and genital or other remote infections are among 
the predisposing causes. 

Symptoms. The essential symptoms of mastitis are pain, swelling, and 
localized tenderness in the breast, together with more or less rise of tem- 
perature. The attack is frequently ushered in by a chill or slight chilli- 
ness. 

When pus forms fluctuation may usually be detected, and a deep red 
or bluish discoloration of the skin is observed at the place where the pus 
comes nearest the surface. Yet fluctuation may be absent in deep-seated 
suppuration, and the evidence usually afforded by the appearance of the 
skin may be wanting, at least for a time, after pus is present. 

Forms. There are three principal forms of mastitis : Glandular, sub- 
glandular, subcutaneous. To the latter two the term perimastitis would 
perhaps more properly apply. The differential diagnosis of these varie- 
ties of mastitis depends upon the source of the infection and the location 
of septic foci, together with the degree of systemic disturbance. 

In the subcutaneous form the lesion is usually single and differs little 
from superficial phlegmon in other parts of the body. In the glandular 
form more pain and more constitutional disturbance are present than in 



562 r.\Tii<>i. <><;y or tiii: rri:iiri:i:iUM. 

the subcutaneous variety; prodromal chill is usual; the lesion is often 
multiple; the gland is indurated, [n the subglandular form the pain is 
deep -rated ami more intense, temperature persistent and high, the gland 
not indurated, and, when suppuration has occurred, it floats upon the 
surface of the fluid. Pus is detected by passing an aspirating needle 
behind the gland. Suppuration may eventuate in any of the forms, de- 
pending upon the patient's lack of power to resist the infection and upon 
the quantity, nature, and virility of the invading parasites. It must not 
he forgotten that two or all forms may coexist. 

Treatment. Prophylactic and Abortive. Milk engorgement is 
combated by training the child early to nurse. The infant should receive 
its first lesson as soon after birth as the condition of the mother will 
permit, usually within six or eight hours, and no effort should be spared 
in teaching the child to suckle before the milk secretion is fully estab- 
lished. The use of the breast-pump, as a rule, is unsatisfactory. It 
frequently fails, and is liable to bruise the breast. 

At the hands of a skilful nurse, massage is often useful for the relief 
of overdistention, either of the entire breast or of single lobules. It is 
contraiudicated in the presence of inflammation, and is permissible only 
when not painful. The breasts should be well oiled in order that the 
nurse's efforts be not expended in mere friction, but be rather a deep 
kneading directed to the gland. The stroking is practised in the direc- 
tion of the lactiferous ducts, from the base of the gland toward the 
apex. 

In hypersecretion the compression binder is an extremely valuable 
measure. It is applied firmly, the pressure being evenly distributed over 
the breast by a moderately thick layer of cotton-wool under the 
binder. An opening in the centre of the cotton compress prevents inju- 
rious pressure upon the nipple. Compression is useful both as a preven- 
tive and an abortive measure in mastitis. 

Topical applications of oleate of atropia are effectual for diminishing 
the milk secretion, but they must be used with care lest the secretion be 
too much repressed. Saline catharsis and the restriction of liquids are 
indicated in over-free secretion. 

Essential for the prevention of mastitis is the preventive and curative 
treatment of nipple lesions. As has already been said with reference 
to the prophylactic care of the mammilla during the early weeks of 
lactation, it must be remembered that prolonged maceration of the nip- 
ple in the child's mouth is injurious. A single nursing need not occupy 
more than ten or, at the most, twenty minutes, and regularity should 
be insisted upon. 

A part of the prophylaxis which must not be overlooked is addressed 
to the general health of the patient. Tonics are indicated in the majority 
of convalescents from childbirth. 

Treatment of Suppuration. When pus forms in either variety 
of mastitis it should immediately be evacuated. An anaesthetic is required 
except in simple subcutaneous abscess. The incision should radiate 
from the nipple to avoid severing the milk-ducts, and should be large 
enough to admit the finger freely. When but one incision is made it is 
to be located at the most dependent point of the abscess-cavity. It is 



ANOMALIES* AND DISEASES OF THE BREASTS AND NIPPLES. 553 

well to avoid the areola, unless the incision can be kept wholly within 
that area. Otherwise an unsightly scar results, owing to pigmentation 
of the cicatrix. 

The finger is then introduced and the cavity thoroughly explored. If 
the abscess be large, and especially if several loculi are found, counter 
openings should be made at remote points. The cavity or cavities are 
then thoroughly irrigated with the normal salt solution or with peroxide 
of hydrogen. A drain of washed-out strip iodoform gauze is placed in 
each opening, and a large compress of aseptic cotton or cheesecloth is 
applied and held firmly by a breast-binder. The dressings must be 
changed daily for six or eight days and the irrigation, as a rule, repeated. 
By the end of that time the incisions may generally be allowed to close. 
One or two soft flexible rubber drainage-tubes for each opening may be 
substituted for the gauze, if preferred, after the first few days. 

Agalactia. 

The causes of agalactia, or diminution of milk secretion to a degree 
below the normal, are general and special. Adynamia of any origin may 
be accompanied with insufficient milk secretion. On the other hand, 
congenital or acquired malformations may be the cause. 

In the cases dependent upon general conditions every effort must be 
made during pregnancy to restore the patient's tone and vigor; and after 
labor liberal quantities of fluid — milk preferably — must be taken. The 
breasts may be stimulated by massage and by daily applications of 
faradism. 

Congenital conditions are not amenable to treatment; whereas, acquired 
malformations, such as stenosis of milk-ducts, or parenchymatous degen- 
erations due to indurative processes, can be modified in some cases by 
timely treatment. 

As inflammatory lesions are the common local causes of these mam- 
mary changes, it is of first importance to prevent their occurrence, and 
if not successful to limit them as much as possible. 

Galactorrhea. 

Galacturrhoea is an excessive secretion of milk which persists after wean- 
ing. The Quantity of milk is very large and its quality thin and watery. 
One or both breasts may be affected, and the condition may seriously 
impair the general health. 

Treatment. Treatment consists in firm compression of the breasts 
with a breast-binder, the exhibition of iodide of potassium, gr. x t. i. d., 
and the persistent use of ergot for a considerable period. Oleate of 
atropia may be applied locally with caution. General tonics and hsema- 
tinics are especially indicated. 

Galactocele. 

Galactocele is a condition in which a mammary acinus becomes dis- 
tended with milk. This may be due to congenital conditions, such as 



554 PATH0L007 OF THE PUEBPEBIUM. 

absence of the duct, Btenosis, or atresia; or may result from inflamma- 
tion. It is single or multiple, and may affect one <>r both breasts, 

Treatment. Treatment is indicated where the condition is pro- 
gressive, and consists either in Laying the cyst open under aseptic pre- 
cautions, and treating it as an abscess-cavity, or dissecting it out and 
dosing the wound at once. 

It must not be forgotten that galactocele sometimes undergoes spon- 
taneous cure, the milk becoming inspissated and, finally, inclosed in a 
shrunken sac and having the consistence of sebaceous matter. 



CHAPTER XXYI. 

PUERPERAL INSANITY. 

The term Puerperal Insanity has been used by some writers to desig- 
nate the forms of mental derangement beginning immediately after 
delivery or at any time between the birth of the child and the termina- 
tion of the nursing period, while others include all those psychoses that 
are coincident with pregnancy, delivery, or lactation. , 

As in so many other mental diseases, there must be a prepared soil, 
which consists in an hereditary predisposition, and here the likeness 
to the so-called periodical and recurrent insanities is most pronounced. 
While primiparw are most likely to develop such mental derangement, 
there are many women who have repeated attacks of puerperal insanity 
as an accompaniment of subsequent accouchements, and doubtless its 
crisal development is oftentimes merely an exacerbation, the patient's 
mental state never being after the first attack an entirely normal one. 
The number of women who for the first time become insane after the 
second or third parturition is small in comparison with those whose dis- 
order attends the first confinement. 

So far as the question of heredity is concerned, it is a well-recognized 
fact that the children born of a mother who develops puerperal insanity 
are quite apt at some future time to become insane. 

Etiology. Undoubtedly there are a large number of factors both 
physical and mental that contribute to the production of insanity at this 
important epoch, and while certain variations take place in the symp- 
tomatology of the insanities coincident with the pregnant state or that 
following birth, the bodily and mental causes very often play a contin- 
uous part. Much stress has been laid upon the sense of shame and 
fear connected with the birth of an illegitimate child, and undoubtedly 
the worry and attendant suspense lead to such mental exhaustion and 
disorder as to end in the overthrow of the patient's ordinary mental 
condition. Strange to say, however, in the majority of cases there 
appears not only to be a gradual evolution of symptoms, except in a 
very small number of melancholic cases, but there are mania and confu- 
sion which are suggestive of a physical cause presently to be more fully 
referred to. It cannot be gainsaid that where conception has been the 
result of guilty intercourse, and where attempts have been made to pro- 
duce criminal abortion, there may be not only very great mental distress 
and apprehension, but an undermining of physical strength, which are 
sufficient in themselves in certain neurotic individuals to lead to insanity. 
In Scotland particularly the influence of illegitimacy is very great, 25 
per cent, of all cases occurring in the experience of one writer being 
those in which the offspring were illegitimate. This, according to Lewis, 
does not appear to be the case in England, where 61 of 66 cases observed 
by him were married women. After all, the importance of this element 

(555 ) 



556 PATHOLOGY OF THE PUEBPEBIUM. 

depends very much upon the moral sensibility and religious training of 
the community. 

Among other psychical influences concerned in the creation of this form 
of insanity may Be enumerated the development of the maternal instinct. 

the tortures of poverty, and the suffering that the woman may undergo 

as the result of neglect or cruelty of her husband. Among the physical 

causes may be mentioned certain conditions of exhaudion which are due 
to over-exertion during the months previous to delivery, the loss of blood 
at this time, or certain imperfectly understood forms of autotoxis. Albu- 
minuria, which in former years was supposed next to local septic infec- 
tion to play a part that would fully account for the puerperal psychosis, 
L6 n<»t nowadays regarded as a sufficient explanation; in fact, the urine 
of the puerperal insane, as a rule, shows the absence of albumin, and 
there are many cases where the disease develops in women whose kidneys 
have from the first been unaffected. The dangers of septic infection from 
the uterine cavity itself have been equally exaggerated. Lusk, whose 
conservative opinions are well known, is disposed to take the view that 
septic infection is more likely to take place when bacteria are introduced 
from outside the body, and suggests that the toxaemia due to the agency 
of the bacterium coli is often at the bottom of wrongly ascribed toxis. 

The writer's recent investigations as to the origin of insanity which is 
due to the absorption of the products of intestinal putrefaction lead him to 
believe that the cause of many cases of puerperal derangement is to be 
found in the large intestine, and that the acute symptoms, which are very 
characteristic, maybe traced to the excessive formation of combined sul- 
phates, and are accompanied by the presence of a large amount of indican 
in the urine. Whether the initial cause be exhaustion or mental worry, 
the disordered metabolism of proteids is a likely consequence. This theory 
is borne out by the investigations made by Lewis about seven years ago, 
namely, that there was a very decided reduction in the amount of haemo- 
globin, which in five of his cases varied from 20 to 78 per cent, of the 
standard of healthy blood, although in one of these cases the oligochro- 
maBinia was due to post-partum hemorrhage. In all the five cases there 
was a lowered corpuscular value, and in one maniacal patient a rather 
sudden reduction attended the maniacal outburst. The well-settled con- 
clusions arrived at by Sir Andrew Clark, SoJkow T ski, and others, and 
verified by the writer's cases, show that the absorption of the products of 
bacterial death invariably result not only in diminished haemoglobin, 
but in various alterations in the number and structure of the corpuscles 
themselves. As familiar causes may be mentioned stoppage of the lochia 
and the consequent retention of septic material, subsequent inflammation 
of the uterus itself, and the various accidents of the puerperal state, 
exhaustion after a protracted labor, an extensive rupture of the perineum, 
the suffering incident to the use of instruments, and the formation of abscesses 
of the breast. 

Symptoms. Two forms of puerperal insanity are ordinarily recognized: 
maniacal and melancholic, the former being much more common than 
the latter, the percentage varying from 70 to 80 of all the cases, and in 
most instances the excited or depressed state differs but little from the 
familiar derangement due to various non-puerperal causes. There are 
certain peculiarities which are so constant, however, as to be considered 



PUERPERAL INSANITY. 557 

characteristic by many, notably the erotic manifestations and the destruc- 
tiveness. The hallucinations and delusions are of a lively and rapidly 
formed kind, and it may be said that, whether the patient is excited or 
depressed, painful emotional states are apt to prevail. The melancholia 
may be of slow or rapid formation, and if it has a dominant feature it 
is the tendency to suicide, which is common. 

Irregular mental disturbances which are so brief as not to fall under 
the ordinary heads of insanity, consist in delirium and temporary dis- 
turbances of a confusional nature. There is also in subjects possessing 
the hereditary tendency a variety of insanity characterized by the com- 
mission of impulsive acts, for which the person is very often held respon- 
sible, her ordinary conduct showing very little or no change. Within 
the first week after delivery the woman may present changes and an 
insanity develop of a most dramatic and violent nature. 

There may or may not be a prodromal condition of ill health, mani- 
fested by loss of appetite, indigestion, constipation, and flatulence; but 
such is apt to be the case. The patient's color is usually pale, the pulse 
becomes irritable and quick, and a restlessness is shown which grows, and 
is associated with irritability, tearfulness, and pitiful complaints in regard 
to petty annoyances. Sleep becomes disturbed and broken, and the patient 
is annoyed by bright lights, noises, the slamming of doors, and is apt 
to be querulous and fault-finding. She expresses no interest in her child, 
and, in fact, does not care to see it, and when it is placed by her she is 
either indifferent or asks for it to be taken away. She turns against her 
husband, whom she subsequently accuses of infidelity; she becomes sus- 
picious of those about her, and may say that her food is poisoned and 
refuse to eat it. As the condition deepens so does the excitement, while 
rapidly formed delusions of persecution — which at first are systematized, 
but afterward become disorderly and without foundation — are expressed. 
Auditory hallucinations as well as those of the other senses are constant, . 
and lead her to express a fear of injury and contamination. In well- 
developed cases the articles about her are declared to be smeared with 
blood. Evil faces peer at her from every side, and she hears voices 
urging her to kill herself or some one else. Some women manifest 
exceedingly erotic eccentricities of conduct, which amount to nympho- 
mania. 

Refined and gentle women will make indecent proposals and write foul 
scrawls, expose their persons, and subsequently defile themselves and their 
bedclothing with their excrement. There are some cases of slower growth 
where the initial disturbance consists in a stolid silence, with a great deal 
of suppressed excitement which finally bursts forth. Cases are known 
in which women remained absolutely mute for a week or more, concealing 
their delusions, and ultimately, within a remarkably brief space of time, 
became incoherent and violent. In the depressed form of trouble there 
may be slowly developed delusions which sometimes have a religious 
coloring, and such patients are apt to accuse themselves of crimes, believ- 
ing that they are the special objects of divine condemnation and are 
hardly fit to live. It is not at all unusual for such a patient to declare 
that her baby is not her own, or if it is, that it must be destroyed as a 
sacrifice, and that she must herself kill it, which she does. Sometimes, 
as a result of delusion she kills herself, or tries to, and it is not unusual 



558 PATHOLOGY OF THE PUEBPEBIUM. 

for her to do thi>, believing thai she is a burden to her husband and 
friends, although in the majority of cases, as has been said, the puerperal 
insane distrust those about them, and are filled with their own unhappy 

importance. The concealed form of the disease is one in which the 

patient may manifest a slight depression which does not reach the dignity 
of simple melancholia, and in which her hysterical conduct or derange- 
ment, regarded, as a rule, as ordinary neurasthenia, in reality disgUU 
most serious psychosis which is appreciated for the first time when some 
sudden and perhaps sueeessful attempt at suicide, or some impulse result- 
ing in destruction of her child or another person, awakens every one to 
the gravity of the masked disease that has perhaps existed for a long 
time. 

The insane erimes of puerperal women are nearly always of a nature 
to suggest an unbalanced mind, and there is none of the concealment 
that belongs to child murder committed by sane persons. 

Regis refers to the fact that homicide is a feature of post-partum 
insanity, while theft and other misdemeanors which imply a sudden 
instigation or a desire to satisfy, are chiefly features of ante-partum 
insanity. 

There is no doubt of the fact that throughout the puerperal state the 
woman has diseased appetites and impulses, and though they may not 
rank very high as evidences of mental deterioration, and may disappear 
entirely after the re-establishment of menstruation, they at some time or 
other find expression in disorderly acts, some being of a criminal nature. 
Destruction of property, incendiarism, and the impulsive propensity to 
steal are not infrequently manifested, and abortive attempts at suicide lead 
to newspaper publicity and possibly to legal prosecution. So far as the 
physical evidences of puerperal insanity are concerned, we find little that 
is distinctive or is not associated with the ordinary insanities. The indi- 
cations of malnutrition in the acute, excited and depressed psychoses are 
generally exaggerated, and those signs of loss of tone of the bodily 
functions which are the expressions of exhaustion appear much earlier 
than they otherwise usually do. Early and obstinate constipation, 
heavily loaded urine, and other indices of gastro-enteric disturbance 
usually commence almost as soon as, and often before, the excitement 
is at all marked, and may eventually resemble the so-called typhoid 
symptoms of various states of exhaustion. Pallor is a characteristic 
appearance which is common to certain other toxic insanities; the skin 
often has a glossy, drawn look, and the breath the so-called starvation 
odor. Some women at a very early time rapidly sink into a delirious 
condition, with occasional periods of consciousness, but without any rise 
of temperature, the state being erroneously called puerperal fever; in 
reality it is a toxaemia which varies in intensity of expression with the 
rapidity of absorption and the virulence of the septic poison. Sometimes 
the mental symptoms, as has been said, are immediately connected with 
the stoppage of the lochial discharge; but the discontinuance of the 
latter is more often an effect than a cause. 

Some writers regard stuporous melancholia to be the type belonging 
specially to puerperal insanity, which, however, is a view the writer can 
hardly take, unless the familiar mute form of the disease is to be so 
regarded; this seems improbable, as the subjects of the latter so often 



PUERPERAL INSANITY. 559 

eventually express a certain intensity of feeling which undoubtedly 
exists in the earlier stages in a repressed form, even when the patient is 
most silent. 

Prognosis. In a large number of cases there is a comparatively prompt 
recovery, especially in puerperal mania. The prognosis is not nearly so 
good in melancholia; but, of course, in both conditions much depends 
upon the treatment. Where an hereditary groundwork exists the situ- 
ation becomes much more grave, and the danger of non-recovery is 
increased by the occurrence of two or more attacks. Regis does not 
regard any form of puerperal insanity to be as curable as simple general- 
ized insanity. He considers that the forms occurring during gestation or 
labor are much more likely to get well than when the affection develops 
at a later period, believing that the insanity of lactation is much more 
serious. 

So far as time is concerned, much depends upon the duration of the 
symptoms and upon the age of the subject. If the physician adopts 
prompt measures the condition may be cut short within a brief space 
of time, especially if the patient be a young woman; but if, as is often 
the case, she enters an asylum after the existence of a mania or melan- 
cholia for several months, her prospects are rather bad, for a certain 
mental involution has taken place which is likely to be permanent 
and progressive. As to age, it may be held that if puerperal insanity 
develops in a woman over thirty the prognosis is much more unfavorable. 
Lewis's figures, which may be taken, show that the recovery-rate may 
even reach a percentage of 80, while 8.5 per cent, represents the mor- 
tality. Of the 80 per cent, who recovered the greater number got well 
before the sixth month, there being 37 out of 68 cases; the others slowly 
recovered. It would also appear from his tables and those of Clouston 
that the sooner patients entered the asylum and were treated, the more 
rapid was their recovery. So far as the writer's experience is con- 
cerned, those who manifested suicidal tendencies or in whom the delusions 
were fixed and limited presented a form of the disease which is the least 
curable. On the other hand, in the ordinary cases, where the delusions 
and hallucinations are general and unstable, the prognosis is fairly good. 
Should a case progress, the termination of dementia is not usually so 
rapid as that of other forms, in this respect resembling the limited delu- 
sional insanities. 

Treatment. Very much tact and care are needed in the early manage- 
ment of puerperal insanity, which is often difficult because of the situa- 
tion of the patient and the prejudices of the family. The interference 
of an anxious husband is too often apt to tie the hands of a physician 
and to prevent him from adopting and using the wise measures of 
restraint that are demanded. Much of this may arise from the non- 
recognition of the serious nature of the complication, the friends of the 
woman believing it to be some temporary disturbance which may be an 
unimportant symptom of the puerperal condition, that will disappear 
in a few days. The early irritability and malaise of the woman are 
rarely appreciated, and the solicitous husband is apt to force his society 
upon his wife or to insist upon leaving the child in bed with her, despite 
her expressions of disgust or indifference. Anxious and sympathetic 
friends insist upon paying visits, and injudicious clergymen attempt a 



560 PATHOLOGY OF THE PUEBPEBIUM. 

moral reform and proffer religious consolation, which has either no effect at 
all, or a harmful one, upon the already deranged woman. ( me of tin- first 
duties of the physician is to Leave heralone with her nurses, who should 
be competent and experienced, and isolation should be rigidly enforced. 

The isolation of the patient should last for a considerable time, and 
even when committed to an asylum it is best that she should he kept awav 
fr.nn other patient-, especially those who are apt to excite of encourage 
her delusions. 

All things being considered, there is no reason why a patient of this 
kind should he removed from home, even if it were proper for her to leave; 
her bed. But where proper facilities for nursing and restraint are not 
available, removal to a well-ordered asylum should he insisted upon as 
soon as the local conditions will permit and the diagnosis is made with 
certainty. It seems hardly necessary to refer to the importance of re- 
moving every possible agent with which the patient might injure herself 
or others; but the frequent tragedies that so often occur through neglect 
of this precaution must excuse a repetition of what may seem to be 
trivial advice. The patient should not be left a moment alone; all window- 
shutters should be properly fastened, and the room should be stripped of 
unnecessary furniture and especially pictures. When the patient is able 
to leave her bed a floor should be devoted, if possible, to her accommo- 
dation, one room being reserved for day use and the other for sleeping. 
It is always advisable to have a sufficient number of nurses to avoid 
fatiguing struggles, and instruments of restraint should not be made use 
of except in very rare instances. Where the mania, however, fol- 
lows exhausting hemorrhage, and where the heart's action is irritable 
and weak, it is, of course, preferable to keep the patient in a recumbent 
position, which may be done by a combination camisole or a strong sheet 
properly fastened at the sides and foot of the bed. Some sort of mechan- 
ical restraint is permissible in destructive cases, and is not nearly so 
exhausting or trying as the injury that is unavoidably done by even 
the most humane nurses in their efforts to control the patient. 

One of the first forms of medicinal treatment consists in the correction, 
if possible, of the intestinal condition as well as that of the uterus and 
vagina. Observers generally call attention to the necessity of the removal 
of sources of peripheral irritation or local infection. An inconsiderable 
focus of septic infection may give rise to an elevation of temperature, 
and is often associated with ill-smelling discharge and some tenderness; 
it is hardly necessary to say that all retained septic material should be 
carefully removed, either by the curette 01 some other means, and the 
mucous membrane of the uterus and vagina should be disinfected. It is 
always well to give the patient a full dose of calomel and soda, which is 
to be followed up by such intestinal antiseptics as the salicylate of soda 
or naphthalin, and the lower bowel as well as the vagina and uterus 
should be douched with solutions of borax, carbolic acid, or the hypo- 
chlorite of soda. 

These douches should be given frequently, and large amounts of liquid 
are to be employed; at the same time the perineum and external organs 
of generation are to be washed frequently with antiseptic solutions, and 
proper precautions are to be taken when the bowels are moved. In some 
instances the use of dilute hydrochloric acid and nux vomica is of 



PUERPERAL INSANITY. 561 

benefit, and at a later stage, when it is possible, lavage is suggested. In 
some patients the condition of exhaustion and depression is very great, 
and the administration of strychnine, either hypodermically or by the 
mouth, is attended with the best results. Of course, one of the earliest 
indications is the provision of remedies to promote sleep and to calm the 
excitement which is so pronounced. Our knowledge of the value of 
intestinal antiseptics leads us to expect most happy effects from the in- 
ternal use of naphthalin, and MacPherson found that many of his most 
excited patients became calm and slept well after a few doses of naph- 
thalin, which may be administered in quantities of five grains three times 
a day, and, if necessary, be increased to fifteen or twenty grains at a 
dose; should a special hypnotic be needed, there is none better than the 
hydrobromate of hyoscin, which may be given in doses of from y^ to 
^g- of a grain, to be repeated, if necessary, until the physiological effects 
are attained. Should this not succeed, the only other remedy worthy of 
much confidence is morphine, though chloral, the bromides, chloralamide, 
or paraldehyde may be tried. "While chloral in light cases is better than 
the last two drugs mentioned, it should never be given to debilitated 
patients, and where the proportion of blood-corpnscles and the percent- 
age of haemoglobin are low, it, as Avell as the bromides, is contraindi- 
cated. In such examples it is much better to prescribe some such drug 
as paraldehyde or chloralamide. The writer does not recommend sul- 
phonal, trional, or others of the series, which sometimes produce sur- 
prisingly bad after-effects. In some restless cases where there is much 
debility, sleep may be produced by large doses of the tincture of digitalis 
or by alcohol. Hydrotherapy is of decided advantage as an adjunct, 
and a hot bath or a cold pack will often succeed where drugs fail. As 
has been said, the feature of puerperal insanity is physical exhaustion 
and malnutrition. It is, of course, necessary to put the patient upon a 
simple nutritious diet, which should consist for a long time of nothing 
but milk in generous quantities, and in the early history of the case it is 
not wise to give eggs or meat or substances which are apt to be imper- 
fectly digested in the intestines. Iron, arsenic, or the gelatinous prepa- 
ration of the phosphate of lime made by Leroy, of Paris, may be used 
at a later stage, with the effect of shortening convalescence. 

So far as mental management is concerned, it is best not to resort to 
any systematic or aggressive measures, the patient being simply protected 
and furnished with congenial amusement, including free exercise in the 
open air. 



36 



CHAPTER XXVII. 

PUERPERAL INFECTION. 

\\\ the term puerperal infection we understand the various morbid 
conditions of the female genital tract and the systemic affections depend- 
ent thereon which result from infection during labor or the puerperium 
by various micro-organisms. These infections are generally designated 
as puerperal fever, but we prefer to avoid the term, as it still suggests 
to many the old idea of the essentiality of the affection, which waa so 
strongly urged in this country by the late Fordyce Barker. 1 It also 
emphasizes the febrile phenomena of the affection, instead of laying 
stress upon its infectious nature aud the consequent responsibility of the 
obstetrician and his assistants. We also prefer the term puerperal infec- 
tion to that of puerperal septicaemia, which has lately come into frequent 
use; for, in many instances, the infection results in perfectly localized 
inflammatory processes, to which the term septicaemia cannot be applied 
without violating the established rules of diction. 

It is probable that puerperal infection has occurred almost as long as 
children have been born, and passages may be found in the works of 
Hippocrates, Galen, Avicenna, and many other of the older writers which 
clearly referred to it. The term puerperal fever, however, is of com- 
paratively recent origin, and was introduced by Willis in 1676, who 
referred to it as " febris puerperarurn." The English term puerperal 
fever, it appears, was first employed by Strother 2 in 1817, and has con- 
tinued in use ever since. 

The ancients regarded the affection as the result of retention of the 
lochia; and this remained the prevalent explanation for its occurrence 
until a comparatively recent date. It was not until the early part of the 
seventeenth century that other explanations were offered, when Plater 
showed that it was essentially a metritis, and was followed in the next 
century by Puzos with his milk metastasis theory. 

From the time of Plater until Semmelweiss 3 (1847) demonstrated its 
identity with wound infection, or, we may say, until Lister demonstrated 
the value of antiseptic surgery, all sorts of theories were suggested con- 
cerning its origin aud nature, the enumeration of which would occupy 
the entire space allotted to us. And we would, therefore, refer those who 
are interested in the history of the affection to the monographs of Eisen- 
mann ( Wund und Kindbettfieber, Erlangen, 1837) and Silberschmidt (His- 
toriscJie-kritische Darstellung der Pathologie des Kindbettfiebers, Gf-eJcrdnte 
Preisschrift, Erlangen, 1859, 131 pp.). 

Organisms Causing Puerperal Infection. In 1847, Semmelweiss, 4 then 
an assistant in the Vienna Lying-in Hospital, began to study the cause of 

1 Barker. The Puerperal Diseases, third edition, 1874. 
- Strother. Critical Essay on Fevers. London, 1718. 

3 Semmelweiss. Die Aetiologie, der Begriff u. die Prophylaxis des Kindbettfiehers Pest. Wien u. 
Leipzig. 1861. 
* Semmelweiss. Op. cit. 

(562) 



PUERPERAL INFECTION. 563 

the frightful mortality attending confinement of women in that hospital, 
as compared with the small number of women succumbing to puerperal 
infection when delivered in their own homes. As a result of his observa- 
tions, he concluded that puerperal iufection was a wound-infection, and 
was due to the introduction of septic material by the examining finger. 
He accordingly obliged every one to disinfect his hands with chlorine 
water before examining the parturient woman, and had the pleasure of 
seeing the mortality fall from 10 per cent, or more to about 1 per cent. 
In spite of the excellent results, his work was scoffed at by many of the 
most prominent men of his time; and it was not until after the discov- 
eries of Lister and the development of bacteriology that his services 
were thoroughly appreciated. Trousseau, 1 in 1858, recognized the same 
fact, and pointed out the identity of puerperal and wound infection in 
the following words: " Quelque chose de specifique s'ajoute a la plaie 
placentaire, a la plaie chirurgicale." 

We shall now briefly consider the organisms which have been proved 
to be causes of puerperal fever. 

(a) Streptococcus. It has been abundantly and conclusively demon- 
strated by many excellent observers that the streptococcus is the usual 
cause of the epidemic and fatal forms of puerperal infection. Before 
the development of cultural methods streptococci were demonstrated by 
many observers in the tissues of women dead of puerperal infection. 
They were first observed in 1865 by Mayerhofer, 2 whose findings were 
confirmed by Coze and Feltz, 3 Eecklinghausen, 4 Waldeyer, 5 Klebs, 6 
Orth, 7 Heiberg, 8 and Landau. 9 To Pasteur 10 (1880) belongs the credit 
of having first cultivated streptococci from cases of puerperal infec- 
tion, when he designated them as " chapel ets en grains." He was 
assisted in this work by Doleris, 11 who carried it on still further and was 
able to demonstrate that streptococci were the usual infectious agents, but 
that staphylococci, and in rare cases bacilli as well, played a part in the 
production of the infection. The researches of Pasteur and Doleris were 
soon confirmed by Fraenkel, 12 Iovanovic, 13 Lomer, 14 Winckel, 15 Bimim, 16 
Doederlein, 17 Winter, 18 Ott, 19 Czerniewski, 20 Widal, 21 and all subsequent 

1 Trousseau. Quoted by Doleris, No. 36. 

2 Mayerhofer. Zur Frage nach der Aetiologie der Puerperalprocesse. Monatsschrift f. Geburtskunde, 
1865, xv. 112. 

3 Coze and Feltz. Gazette med de Strassburg, 1869, p. 30. 

4 Recklinghausen. Cent. f. med. Wissenscbaften, 1871, 713. 

5 Waldeyer. Ueber das Vorkommen von Bakterien bei der diphtherischen Form des Puerperal- 
fiebers. Arch. f. Gyn., 1872, iii. 293. 

6 Klebs. Archiv f. exper. Path., Bd. v. p. 417. 

7 Orth. Virchow's Archiv, lviii. 441. 

8 Heiberg. Die puerperalen und pyamischen Processe, 1873. 

9 Landau. Ueber puerperalen Erkrankungen. Arch. f. Gyn., 1874, vi. 147. 

10 Pasteur. Septicemic puerperale. Bull, de l'Acad. de Med., 1879, 260, 271. 

11 Doleris. Essai sur la pathogenie et la therapeutique des accidents infectieux des suites de 
couches. These de Paris, 1880. 

12 Fraenkel. Quoted by Lomer. See below. 

13 Iovanovic. Quoted by Lomer. See below. 

14 Lomer. Ueber den heutigen Stand der Lehre von der Infectiontragern bei Puerperalfieber. Zeit. 
f. Geb. u. Gyn., 1884, x. 366. 

15 Winckel. Zur Lehr von dem internen puerperalen Erysipel. Verh. d. deutschen Ges. f. Gyn., 
1886, 78. 

16 Bumm. Die puerperale Wundinfektion. Cent. f. Bakteriol., 1887, ii. 343. 

w Doederlein. Untersuchung liber das Vorkommen von Spaltpilzen in den Lochien des Uterus und 
der Vagina gesunder und kranker Wbchnerrinnen. Arch. f. Gyn., 1887, xxxi. 412. 

18 Winter. Die Mikroorganismen in Genitalkanal der gesunden Fraun. Zeit. f. Geb. u. Gyn., 1888. 
xiv. 443. 

i9 Ott. Zur Bakteriologie der Lochen. Arch. f. Gyn., 1888, xxxii. 436. 

20 Czerniewski. Zur Frage von den puerperalen Erkrankungen. Eine bakteriologische Studie. Arch. 
f. Gyn., 1888,,xxxiii. 73. 

21 Widal. Etude sur l'infection puerperale. These de Paris, 1889. Infection puerperale et phleg- 
matia alba dolens. Gaz. des hop., 1889, 565. 



564 PATH0L007 OF THE PUEBPERWM. 

observers; bo thai at the present time it is universally admitted that 
the Btreptococous pyogenes is the direct causative agent in mosl cases of 
puerperal infection. 

(6) Staphylococcus. While streptococci are usually the causative 
agents io puerperal infection, it has gradually been demonstrated that 
they are not necessarily the only organisms which may he concerned in 
it- production, and it has been clearly shown that most of the pus- 
proaucing organisms which may be concerned in wound-infection may, 
likewise, occasionally give rise to puerperal infection. 

Brieger, 1 in 1888, was the first to demonstrate that puerperal infection 
might he due to staphylococci, when he reported autopsies upon seven 
cases, in five of which he was able to demonstrate the staphylococcus 
aureus. Doleris, 2 in his thesis of 1880, stated that he was able to culti- 
vate in pure culture a coccus which was arranged in groups or bunches, 
but it was not until 1894 3 that he stated definitely that they were staphy- 
lococci. The observations of Brieger 4 were soon confirmed by other 
observers, among whom may be mentioned Czerniewski/' Fehling, 6 
Haegler, 7 Doederlein, 8 Widal, 9 Mironow, 10 Netter and Bounaire, 11 Sabrazes 
and Faquet, 12 Kronig, 13 and Strunckmann. 

It was stated by Fehling 14 and Haegler 15 that staphylococci usually 
give rise to mild forms of infection. But this is not borne out by the 
observations of other authors. Occasionally mixed infections with the 
staphylococcus and streptococcus are observed, as reported by Doeder- 
lein 16 and Bar and Tissier. 17 It appears that the staphylococcus aureus 
is the variety observed in puerperal infection, while the albus and citreus 
play little or no part in its production. 

(c) Gonococcus. It has long been believed by clinicians that gonor- 
rhoea not infrequently plays a part in the production of puerperal infec- 
tion. But it was not until 1893 that Kronig 18 adduced bacteriological 
proof of its action. He then reported nine cases of mild infection, in 
all of which he was able to obtain pure cultures of gonococci from the 
uterine lochia. In a recent communication 19 he states that he was able 

I Brieger. Ueber bakteriologische Untersuchungen bei einigen Fiillen von Puerperalfieber. Charite 
Annaleu. 1888, xiii. 198. 

'-' Doleris. Essai sur la pathogetiie et la therapeutique des accidents infectieux des suites de couches. 
These de Paris, 1880. 

3 Doleris. Inflammation puerperale. Nouve. Archives d'obst et de gyn., 1894, ix. 97-122, 142-161. 

4 Brieger. Ueber bakteriologische Untersuchungen bei einigen Fiilleu'von Puerperalfieber. Charite 
Annalen, 1888, xiii 198. 

5 Czerniewski. Zur Frage von den puerperaleu Erkrankungen. Eine bakteriologische Studie Arch, 
f. Gyn., 1888, xxxiii. 73. 

6 Fehling. Ueber Selbstinfektion. Verhand. deutsche Ges. f. Gyn.. 1889, Freiburg 

7 Haegler. Quoted by Fehling, Physiologie und Path, des Wochenbetts. Stuttgart, 1890. 

8 Doederlein. Klinisches und Bakteriologisches liber eine Puerperalfieber-epidemie. Arch. f. Gyn., 
1891. xl. 99. , 

y Widal. Etude sur l'infection puerperale. These de Paris, 18S9. Infection puerperale et phleg- 
matia alba dolens. Gaz. des hop., 1889, 565. 

10 Mironow. Ueber die Ursachen der puerperalen Erkrankungen. D. I. Charkow, 1889. Referat. 
Cent. f. Gyn., 1891, 678-80. 

II Xetterand Bonnaire. Quoted by Doleris, No. 36. 

w Sabrazes and Faquet. Infection puerperale staphylococcique, etc. Gaz. des hop., 1894, 1039-41. 

13 Kri'>nig. Aetiologie und Therapie der puerpera'len Endometritis. Cent. f. Gyn., 1895, 422-32. 
Discussion Uber Endometritis. Verh. d. deutscheu Ges. f. Gyn., 1895, 498-502. 

H Fehling. Ueber Selbstinfektiou. Verhand. deutsche Ge's. f. Gyn., 18^9, Freiburg. 

15 Haegler. Quoted by Fehling. Physiologie und Path, des Wochenbetts. Stuttgart, 1890. 

10 Doederlein. Klinisches und Bakteriologisches liber eine Puerperalfieber-epidemie. Arch. f. 
Gyn., 1891, xl 99. 

17 Bar and Tissier. La Semaine med., 1S96, 155. Serotherapie dans l'infection puerperale. L'Ob- 
Stetrique, 1S96, 97-128 and 204-217. 

ls Kronig. Vorlaufige Mittheilung iiber Gonorrhoea im Wochenbett. Cent. f. Gyn., 1893, 157. 

19 Kriinig. Aetiologie und Therapie der puerperalen Endometritis. Cent. f. Gyn., 1895, 422-32. 
Discussion uber Endometritis. Verh. d. deutscheu Ges. f. Gyn., 1895, 498-502. 



PUERPERAL INFECTION. 565 

to cultivate the gonococcus in 50 out of 179 cases presenting febrile puer- 
peria, and has thus shown that it plays an important part in the pro- 
duction of puerperal disease. None of these cases resulted in death, and 
the great majority recovered spontaneously. 

Leopold 1 also reports similar cases, and Maslowsky 2 and Neumann/ 3 
in two recent articles, state that they were able to demonstrate the gono- 
coccus in the tissues in cases of endometritis decidual 

(d) Bacillus Coli Communis. In the writer's article 4 upon puer- 
peral infection from a bacteriological point of view (1893), he stated 
that von Franque 5 had cultivated the colon bacillus from a case of 
puerperal infection, and expressed the belief that it would be demon- 
strated more frequently in the future. Subsequent work has amply 
fulfilled this prediction, and we can now point to a long series of cases 
due to this organism. A priori, this is what should be expected when 
we consider the proximity of the genital tract to the rectum and the 
ease with which contamination may occur when the obstetrician infringes 
the strict rules of asepsis. 

Some idea of the abundance of the colon bacillus may be gained by 
the consideration of the figures of several French observers; thus, Yignal 6 
states that one decigramme of feces contains about twenty millions of colon 
bacilli; and Gilbert and Dominici 7 estimate that from twelve to fifteen 
billions are daily excreted with the feces. It thus becomes apparent that 
the examining finger cannot avoid contamination with these organisms if 
it comes in contact with a non-disinfected perineum. 

Infection with the colon bacillus has been observed by Mironow, 8 
Ahlfeld, 9 Eisenhardt, 10 DemelinJ 11 Parmentier, 12 Gebhard, 13 Chantemesse 14 
and Widal, Marmorek, 15 Charpentier, 16 Kronig, 17 Bar and Tissier, 18 and 
myself in several unreported cases. 

Gebhard 19 demonstrated its presence in seven cases of tympania uteri, 

1 Leopold. Ueber gonorrhoiscb.es Fieber in Wochenbett bei einer innerlich nicht untersucbten 
Gebarenden. Cent. f. Gyn., 1893, 675. 

2 Maslowsky. Zur Aetiologie der vorzeitigen AblQsung der Placenta vom normalen Sitz. Monats. 
f. Geb. u. Gyn., 1896, iv. 212-218. 

3 Neumann. Ueber puerperalen Uterusgonorrhoea. Monats. f. Geb. u. Gyn., 1896, iv. 109-116. 

4 Williams. Puerperal Infection Considered from a Bacteriological Point of View, with Special 
Reference to the Question of Auto-infection. Amer. Journ. Med. Sci., July, 1803. 

5 v Franque. Bacteriologische Untersuchungen bei normalen und fieberhaftem. Wochenbett. 
Zeit. f. Geb. u. Gyn., xxv. 277, 1893. 

6 Vignal. Sur Taction des micro-organisms de la bouche et des matieres fecales. Comptes-rend. 
de la Soc. Biol., Aout., 1887. 

"• Gilbert and Dominici. Recherches sur le nombre des microbes du tube digestif. Semaine m6d., 
1894, p. 76 

s Mironow. Ueber die Ursachen der puerperalen Erkrankungen. D. I. Charkow, 1889. Referat. 
Cent. f. Gyn., 1891, 678-80. 

9 Ahlfeld. Beitrage zur Lehre vom Resorptionsfieber in der Geburt und im Wochenbette und von 
der Selbstinfektion. Zeit. f. Geb. u. Gyn., 1893, xxvii. 466-519. 

10 Eisenhardt. Puerperale Infektion mit todlichen Ausgang verussacht durch Bakterium coli com 
mune. Arch. f. Gyn., 1894, xlvii. 189-202. 

11 Demelin. Quoted by Barbier. Des pseudo-infections puerperales d'origine intestinale. These de 
Paris, 1894. 

12 Parmentier. Quoted by Barbier. Des pseudo-infections puerperales d'origine intestinale. These 
de Paris, 1894. 

13 Gebhard. Bacterium coli commune aus Fallen von Tympania uteri geziichtet. Verh. deutsche 
Ges. f. Gyn., 1893, 305. 

" Chantemesse. Bulletin med., 1891, p. 1139. 

!5 Marmorek. Le streptocoque et le serum antistreptococcique. Annales de l'lnst. Pasteur, 1895, 
ix. 593-620. 

16 Charpentier. Serotherapie anti-streptococcique applique au traitement de la fievre puerperale. 
La Semaine gyn., 1896, 89-92, No. 12. 

17 Kronig. Ueber Fieber intra-partum. Cent. f. Gyn., 1894. 749. 

18 Bar and Tissier. La Semaine med., 1896, 155. Serotherapie dans l'infection puerperale. L'Ob- 
stetrique, 1896, 97-128 and 204-217. 

19 Gebhard. Bacterium coli commune aus Fallen von Tympania uteri geziichtet. Verh. deutsche 
Ges. f. Gyn., 1893, 305. 



566 PATHOLOGY OF THE PUERPEBIUM. 

either alone or in combination with other organisms; and Galtier 1 states 
that it La the organism most frequently concerned In its production. 

In not a few cases it Is associated with the streptococcus, as has been 
observed by Marmorek, 2 Charpentier, 8 Bar and Tissier, 4 and the writer 
the former observers stating that the combination appears to augment 

the virulence of the BtreptOCOCCUS and gives rise to very intense affec- 
tions. Whether the future will demonstrate the accuracy of their state- 
ments remains to he seen. 

(e) Bacillus DlPHTHERLSJ. Until very recently it was believed that 
the "diphtheritic deposits" upon the vagina and the interior of the 
puerperal uterus were due to the streptococcus alone, and had nothing to 
do with true diphtheria. But the recent observations of Nisot, "' Bumm/ 
and the writer 7 show that this is not always the case, for we reported cases 
in which we were able to cultivate the Klebs-Loeffler bacillus from the 
diphtheritic membrane in the vagina and to cure the affection by the use 
of the anti-diphtheritic serum. 

(/) Pneumococcus. Cases have been reported by Weichselbaum 8 
and Czemetschka 9 in which the micrococcus lanceolatus has been demon- 
strated in the puerperal uterus. In the case reported by the former the 
genital infection was the primary lesion, while in the latter case it was 
the result of systemic infection. And Bar and Tissier 10 have lately 
reported a case of sepsis in which it was associated with the streptococcus. 

(g) The Bacillus Aerogenes Capsulatus (Gas Bacillus). As 
our knowledge concerning the gas bacillus of Welch has become more 
accurate, it has been shown that it may also occasionally be concerned in 
puerperal infection. In 1896 the writer observed a case in which its 
presence was demonstrated, and which was described by Dr. Dobbin in 
the Bulletin of the Johns Hopkins Hospital. Briefly stated, the case was 
as follows: The aid of the out-patient obstetric department of the Johns 
Hopkins Hospital was solicited in the case of a Bohemian woman with 
a generally contracted pelvis, who had been in labor for some three to four 
days under the care of a midwife. When the writer saw the patient he 
found the head of a macerated child firmly engaged in the superior strait, 
with the uterus tetanically contracted. A fetid dark-colored discharge, 
which contained many gas bubbles, was escaping from the vagina with a 
crackling sound. Owing to the softened condition of the child's head, 
several futile attempts at delivery were made, and we were finally forced to 
deliver it with Tarnier's basiotribe. The mother was profoundly infected 
at the time of delivery, and died the next day. A few hours after death 
the body rapidly became intensely swollen by the development of gas 

1 Galtier. De l'infection primitive du liquide amniotique apres la rupture preraaturee des mem- 
branes de l'oeuf humain. These de Paris, 1895. 

2 Marmorek. Le sireptocoque et le serum antistreptococcique. Annales de l'lnst. Pasteur, 1895, 
ix. 593-620. 

3 Charpentier. Serotherapie anti-streptococcique applique au traitement de la fievre puerperale. 
La Semaine gyn., 1896, 89-92, No. 12. 

4 Bar and Tissier. La Semaine med., 189G, 155. Serotherapie dans l'infection puerperale. L'Ob- 
Stetrique, 1896, 97-128 and 2C4-217. 

B Nisot. Diphtherie vagino-uterine puerperale. Serotherapie guerison. Annales de Gyn., 1896, 
xlv. 259. 
e Bumm. Ueber Diphtherie und Kindbettfieber. Zeit. f. Geb. u. Gyn.. 1895, xxxiii. 126-136. 

7 Williams. Puerperal Diphtheria. American Journal of Obstetrics, August, 1898. 

8 Weichselbaum. Wien. klin. Woe hen . 1888, Xo. 28. 

9 Czemetschka. Zur Kenntniss der Pathogenese des puerperalen Infektion (Metrolymphangitis post 
partum) als Metastase anderweitiger durch Diplococcen bedingter Ertrankungen. Prager med. 
Wochen., 1894. xix. 233. 

10 Bar and Tissier. Serotherapie dans l'infection puerperale. L'Obstetrique, 1896, 97-128 and 204-217. 



PUERPERAL INFECTION. 567 

in the subcutaneous tissues, and soon nearly doubled its original size. 
The same changes were observed in the foetus and in the placenta, and 
we were able to demonstrate the presence of the gas bacillus in the foetal 
and placental tissues, as well as in the uterine lochia. Unfortunately, 
no autopsy was allowed upon the mother, and we were, therefore, unable 
to say to what extent the organisms had penetrated into her tissues. 

Well-authenticated cases of iufection with this organism have been 
reported by Stewart 1 and Ernst 2 following abortion. Cases have also 
been reported by Kronig 3 and Doleris 4 which were probably due to the 
gas bacillus, but the published bacteriological details are too meagre to 
permit of positive statements. 

(h) Bacillus Typhosus. From the uterine lochia of an infected 
woman admitted to the Johns Hopkins Hospital five days after labor 
we were able to isolate the streptococcus, the staphylococcus aureus, the 
typhoid bacillus, and an unidentified anaerobic gas-producing bacillus. 
The patient's blood serum possessed the characteristic Widal reaction, 
but all other symptoms of typhoid fever were absent, and we are inclined 
to believe that the typhoid bacilli were introduced into her genital canal 
by the hand of the midwife, along with the other organism, as we learned 
that she was delivered upon the same bed upon which her husband died 
of typhoid fever a few days before she fell into labor. 

Further details of the case may be found in an article by the writer in 
the Centralblatt f. Gynakologie, September, 1898, and also one by Dr. 
Dobbin in the American Journal of Obstetrics, September, 1898. 

(i) Bacillus Sepsis. Isolated cases reported by Fraenkel, 5 Doleris, 6 
Widal, 7 Mixius, 8 and Goldscheider 9 tend to show that certain cases of 
fatal infection may be due to bacilli with whose properties we are as yet 
unacquainted. But the bacteriological work upon which these statements 
are based is not of a character to enable us to be at all sure about the 
organisms in question, much less to classify them. 

Sapraemia. Beside the cases in which the infection is due to the growth 
and extension of micro-organisms within the body, there is a large class 
of cases in which the symptoms are due to the absorption of toxic 
products produced by organisms within the uterus or elsewhere in the 
generative tract which do not make their way into the blood-current. 
To this form of infection Matthews Duncan, some years ago, applied the 
term " saprsemia/' which has continued in use ever since. It is usually 
thought to be due to the invasion of the uterus by putrefactive organ- 
isms, with whose properties we are as yet almost totally unfamiliar. 

There is no doubt that the term has been grossly abused and that many 
cases have been included under it which really are due to infection with 
the ordinary pyogenic organisms, and at the present time we are hardly 
justified in considering a case as sapraemic unless the lochia have 

1 Stewart and Baldwin. Bacillus aerogenes capsulatus. Case. Columbus Med. Journ., Aug. 1893. 

2 Ernst. Ueber einen gasbildenden Anaeroben in menschlichen Korper und seine Beziehung zur 
Scbaumleber. Virchow's Arch., cxxxiii. Heft ii. 

a Kronig. Discussion iiber Endometritis. Verh. d. deutschen Ges. f. Gyn., 1895, 498-502. 

* Doleris. Inflammation puerperale. Nouv. Archives d'obstet. et de gyn., 1894, ix. 97-122, 142-161. 

5 Fraenkel. Quoted by Lomer. See below. 

6 Doleris. Inflammation puerperale. Nouv. Archives d'obstet. et de gyn., 1894, ix. 97-122, 142-161. 

7 Widal. Etude sur l'infection puerperale. These de Paris, 1889. 

8 Mixius. Bakteriologische Untersuchungen einiger Falle puerperaler Sepsis. D. I. Berlin, 1892. 

9 Goldscheider. Klinische und bakteriol. Mittheilungen iiber Sepsis puerperalis. Charite Annalen, 
1893, xviii. 164-242. 



568 PATHOLOGY OF THE PUEBPEBIUM. 

been examined bacteriologically and found to be free from pyogenic 
organisms. 

This statement is borne out by the observations of Bumm, 1 who found 
streptococci in eight out of eleven cases which were clinically designated 
as sapremia. Von Franque 8 was, likewise, able to cultivate streptococci 
in pure culture from a case which exhibited the clinical picture of sapre- 
mia, ami as the result of his observations stated that ,- sapneiuic fever 
in the puerperium is extremely rare, and it should only be diagnosed 
when an accurate biological examination of the uterine lochia has demon- 
strated the absence of pathogenic and the presence of saprophytic organ- 
isms." 

The organisms entering into the causation of sapreniia are mostly of 
an anaerobic nature, and, therefore, cannot be cultivated in the usual cul- 
ture media. Many of them are gas producers, and thus cause the frothy, 
ill-smelling secretion which is so characteristic of these cases. There is 
certainly a great variety of organisms which may be concerned in the 
production of saprcernia, though only a few have as yet been isolated. 
Thus, Bumm 3 was able to cultivate from a case an anaerobic bacillus, 
which decomposed albumin and produced poisonous substances; and 
Doederlein, 4 in another case presenting a frothy, purulent secretion, was 
able to isolate an anaerobic gas-producing coccus. Kronig 5 in 43 abnor- 
mal puerperia found organisms which did not grow on the usual media, 
and in 32 of them obtained organisms which only grew anaerobically. 

Beside the organisms which w r e have mentioned, it is not unlikely that 
further research will show still other organisms which may play a part 
in the production of isolated cases of infection; but from what we have 
already said it is rendered perfectly clear that the organisms usually con- 
cerned are the well-known pyogenic organisms (streptococcus, staphy- 
lococcus, colon bacillus, and gonococcus) and the various putrefactive 
organisms. 

Some idea of the frequency with which the different organisms are 
concerned in the production of the puerperal infections may be gained 
by recurring to the work of Kronig, 6 who examined 179 cases of puer- 
peral endometritis bacteriologically, and, as a result of his observations, 
divided them into three groups, namely, pyogenic, gonorrhoea^ and sapraB- 
mic. The pyogenic group comprised 79 cases, in 75 of which the infec- 
tive agent was the streptococcus, and in 4 the staphylococcus. In 50 
cases he was able to demonstrate the presence of the gonococcus, and in 
43 of the 50 saprsemic cases he was able to demonstrate organisms which 
did not grow on the usual culture media, 32 of which were anaerobic. 

The writer has examined the uterine lochia bacteriologically in 57 
cases in which the temperature rose to 107° F. or higher during the first 
ten days of the puerperium, and found 

1 Bumm. Histologische Untersuchungen iiber die puerperale Endometritis. Arch. f. Gyn., 1891, 

2 v. Franque. Bakteriologische Untersuchungen bei normalem und fieberhaftem. Wochenbett. 
Zeit. f. Geb. u. Gyn . 1893, xxv. 277. 

3 Bumm. Ueber die Aufgaben weiterer Forschungen auf dem Gebiete der puerperalen Wundin- 
fektion. Arch. f. Gyn., 1889. xxxiv. 325. 

4 Doederlein. Vorlhufige Mittheilung iiber weitere bakteriologische Untersuchungen des Scheiden- 
sekretes. Cent. f. Gyn., 1894, 779. 

5 Kriinig. Aetiologie und Therapie der puerperalen Endometritis. Cent. f. Gyn., 1895, 422-432. 
Discussion iiber Endometritis. Verh. d. deutschen Ges. f. Gyn., 1895, 498-502. 

6 Kronig. Op. cit. 



PUERPERAL INFECTION. 569 

Streptococci in 14 cases. 

Staphylococci iu 5 " 

Gonococci in 2 " 

Colon bacilli in 6 " 

Typhoid bacilli in 1 " 

Diphtheria bacilli in 1 " 

Gas bacilli in 1 " 

Unidentified anaerobic bacteria in 6 " 

Unidentified aerobic bacteria in 3 " 

Bacteria seen in cover-slip preparations, but which will not grow upon 

any medium 14 " 

Absolutely sterile 14 " 

The difference between the figures given and the number of cases exam- 
ined is due to the fact that he had to deal with mixed infections in a 
number of cases. 

Pathological Anatomy. After having thus considered more or less in 
detail the organisms which play a part in the production of puerperal 
infection, we now turn to the consideration of the lesions produced by 
them. 

The lesions occurring in puerperal infection may vary very greatly in 
a given case; and it is probably for this reason that the older authors did 
not earlier appreciate the true nature of the affection. The lesions may 
vary from a coated perineal tear to an inflammatory precess involving 
the entire generative tract, and in many cases extending beyond it to the 
parametrium or peritoneum, and sometimes resulting in a general pyaetnic 
infection. In other cases the infectious elements pass through the port 
of entry with such rapidity that they do not there give rise to local lesions, 
but produce a septicaemia, which is rapidly fatal. The most fatal forms 
of puerperal septicaemia end with extreme rapidity, and have been well 
designated by the French as " sepsis foudroyante." In most cases of 
puerperal infection, however, the endometrium is the portion affected, 
and in the majority of cases the disease remains limited to it, and is 
designated as septic or putrid endometritis, according as it is the result 
of the invasion of pyogenic or putrefactive organisms. 

In puerperal infection any portion of the generative tract may be the 
seat of the lesion, and in many cases more than one portion is involved, 
and we accordingly have to consider puerperal vaginitis, endometritis, 
metritis, parametritis, metro-lymphangitis, metro-phlebitis, salpingitis, 
oophoritis, peritonitis, pyaemia, and phlegmasia alba dolens. 

We shall now take up the consideration of the various lesions more in 
detail, and first turn our attention to those occurring about the vulva and 
vagina. In the pre-antiseptic period the puerperal ulcer was of very 
frequent occurrence; but with the introduction of aseptic methods into 
midwifery its frequency has been markedly diminished, so that it is now 
of very rare occurrence. 

These ulcers occur on the surface of the tears about the vulva and 
perineum, and soon take on a dirty, greenish-yellow appearance, which 
is due to necrosis, and are bathed by a dirty purulent secretion. 

In some cases the ulcers take on a marked diphtheritic appearance, 
and were formerly designated as " diphtheritic ulcers;" but careful his- 
tological observation has shown that they have nothing in common with 
diphtheria except their external appearance. 

As a rule, the puerperal ulcers about the vulva give rise to very little 



570 PATHOLOGY OF THE PUEBPEBIUM. 

systemic disturbance, and would frequently pass unnoticed were it not 
for ocular inspection. 

Puerperal Vaginitis may occur in two forms : cither as a diffuse, 
general inflammation, when the mucosa becomes thickened, soft, and 
reddened, and bathed with an abundant purulent secretion. Or in other 
oases, and especially when torn surfaces are present, a diphtheritic 

appearance may ensue, and a larger or smaller portion of the vagina he 
covered by a pseudo-diphtheritic membrane. This membrane mav vary 
in extent from a small patch covering a slight tear to a complete cast •»}' 
the entire vaginal canal. 

Until the last year it was believed that none of the so-called cases of 
diphtheria of the vagina were due to the invasion of the bacillus diph- 
theria 1 . But the recent observations of Bumm, 1 Nisot, 2 and the writer 
show that in rare instances we may have to deal with true diphtheria 
of the vagina caused by the Loeffler bacillus. 

Endometritis. The most usual lesion in puerperal infection is an 
inflammation of the lining membrane of the uterus. When we recall 
the condition of the uterus immediately post partum, with its bleeding 
surfaces, its large amount of recently torn tissue, and the large gaping 
thrombosed placental sinuses, we readily see how organisms which have 
been introduced into the uterus during labor easily find entry into its 
tissues. And when we consider the mechanism by which the decidua is 
normally removed, we readily see that a choice culture medium is prepared 
by nature for the reception and propagation of organisms introduced 
from without. 

In puerperal endometritis the infection may be limited to the placental 
site, or may extend over the entire mucosa. When the placental site 
alone is infected, we usually find the organisms growing into the thrombi 
and producing comparatively little local reaction. But when the entire 
internal surface of the uterus is affected, we may have the endometrium 
converted into a stinking, sloughing surface, made up of necrotic mate- 
rial and decidual debris, and bathed with a bloody, purulent discharge. 
The necrotic material soon takes on a dirty, yellowish-green appearance, 
and in many instances we find ulcerated surfaces coated with fibrin and 
presenting the clinical picture of diphtheria. This form of endometritis 
was formerly designated as diphtheritic endometritis, but, as stated 
w 7 hen considering the vagina, we do not have to deal with a true diph- 
theria, but simply with a fibrinous exudation, the result of an intense 
infection with the usual pyogenic organisms. 

When the infection is due to the invasion of the streptococcus or 
staphylococcus, there is usually very little odor accompanying it, but 
wdien it is due to invasion by the colon bacillus or any of the various 
putrefactive organisms, we find the interior of the uterus bathed with a 
profuse foul-smelling discharge which frequently contains gas bubbles. 
The amount of necrotic material produced in puerperal endometritis is 
often very great, and, after curetting, it may recur with great rapidity. 
Fig. 353 represents the uterus from a case of puerperal infection due to 
the streptococcus and colon bacillus, in wdiich the woman succumbed ten 

i Bumm. Ueber Diphtherie und Kindbettfieber. Zeit. f. Geb. u. Gyn., 1885, xxxiii. 126-136. 
- Xisot. Diphtherie vagino-uterine puerperale. Serotherapie guerison. Annates de Gyn., 1896, 
xlv. 259. 



PUERPERAL INFECTION, 571 

days after the birth of the child, having been curetted three or four days 
before death, when it was said the uterus was scraped perfectly clean. A 
glance at the drawing, however, shows the entire uterine cavity filled with 
necrotic material, which in all probability was produced in the interval 
elapsing between the curettage and the time of death. 

In most cases the infection remains limited to the endometrium, but 
in many others it progresses beyond it, giving rise to a metritis, a lym- 
phangitis, or a phlebitis, as the case may be. The extension of the pro- 
cess beyond the endometrium usually occurs through the lymphatics, and 
we may trace in their course areas of inflammation extending from the 
endometrium to the peritoneal surface of the uterus. In other cases, and 
especially where the infection has been limited to the placental site, we 

Fig. 353. 




Uterus from patient dying on tenth day from a pure streptococcus infection. 

find that the thrombi have been invaded by the micro-organism, result- 
ing in a phlebitis which may remain limited to the uterine wall, or may 
rapidly extend beyond it and give rise to the various thrombotic forms 
of puerperal infection. 

It would appear that the lesions produced in the endometrium vary 
very considerably according to the micro-organisms concerned, and also 
according to their virulence. In the cases in which we have to deal with 
a virulent streptococcus or staphylococcus infection, the changes produced 
in the endometrium are comparatively slight, the process rapidly spread- 
ing through the lymphatics or veins past the uterus, and giving rise to 
a peritonitis or a general systemic infection. Whereas, in the cases due 



572 



PATHdLOQY OF THE rUERPERIUM. 



to the putrefactive organisms, and also those due to the colon bacillus 
ami to the ordinary pus-organisms of Lesser virulence, the process remains 
more or less limited to the endometrium and gives rise to marked local 

lesion-. Pig. 354 represents the uterus from a woman dying of puer- 
peral infection, in which the infectious agenl was a virulent streptococcus, 
and in this it 18 -ecu that the interior of the uterus IS almost perfectly 
smooth, and presents nothing which could have been removed by means 
of the curette, and stands in marked contrast to the case figured above, 
in which the infectious agents were the streptococcus and colon bacillus. 



Fig. 354. 




Uterus from patient dying on tenth day from a mixed infection— streptococcus and colon bacilli. 

When we consider the histology of puerperal endometritis we find 
that these differences are still further accentuated. Most of our knowl- 
edge on this point we owe to the researches of Bumm 1 and Doederlein, 2 
both of whom have show T n that there is a marked histological differ- 
ence between putrid and septic endometritis. According to Bumm, in 
sections of putrid endometritis we find a thick layer of necrotic material 



1 Bumm. Histologische Untersuchungen iiber die puerperale Endometritis. Arch. f. Gyn., 1891, 
xi. 398. 

2 Doederlein. Die Beziehungen der Endometritis zu den Fortpflanzungs vorgangen. Verh. d. 
deutschen Ges. f. Gyn., 1895, 224-42. 






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PLATE XXI 

FIG. 1. 



*6 9~ - * ** 









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Section through Decidua from Putrid Endometritis, removed by Curette on 

Ninth Day. (Bumm.) 
a. Necrotic tissue swarming with bacteria, b. Zone of reaction, showing nuclei of leucocytes. 

FIG. 2. 



... 



Section through Decidua. Septic Endometritis, Curetting 

on Seventh Day. (Bumm.) 

a. Necrotic tissue, bacteria in masses, b. Resisting-zone of leucocytes, c. Lumen of glands. 

d. Cross-section of bloodvessels, e. Remnants of epithelial cells of uterine glands. 

FIG. 3. 









Streptococci growing between Muscle- fibres. (Bumm.) 



PUERPERAL INFECTION. 573 

lining the uterine cavity, and embedded in it large numbers of the offend- 
ing micro-organisms. Beneath this we find a thick layer of small-cell 
infiltration, which we may designate as the zone of reaction, and beneath 
it more or less normal tissue. Careful study of the sections shows us 
that the micro-organisms are limited almost entirely to the superficial 
necrotic layer; a few may be found in the reaction zone, but none in the 
tissues beneath it, thus showing nature's mode of preventing the invasion 
of the body by the micro-organisms. (See Plates XXI. and XXII.) 

These pictures are observed not only in the cases due to infection with 
the putrefactive organisms, but also in those cases in which the pyogenic 
organisms possess only a slight degree of virulence. On the other hand, 
in cases of septic endometritis, and especially where the organisms are 
virulent, we observe a totally different appearance. Here we likewise 
find adjoining the uterine cavity a layer of necrotic material, which, how- 
ever, is usually thinner than in the preceding case. In this we find 
micro-organisms. The zone of small-cell infiltration is either lacking or 
very imperfectly developed, and we observe the micro-organisms making 
their way down through the decidua, and along the lymphatics through 
the muscular wall of the uterus out to its peritoneal surface. The writer 
has been able abundantly to confirm the observations of Bumm, and 
there is no doubt that his conclusions are amply justified. 

The effect produced by various micro-organisms was strikingly illus- 
trated in one of the writer' s cases, in which he had to deal with a double in- 
fection with the streptococcus and colon bacillus. On making sections 
through the uterine wall in this case we observed the characteristic necrotic 
zone lining the cavity of the uterus, and in it were both forms of micro- 
organisms. Beneath this the zone of small-cell infiltration was fairly 
well developed, and in its upper part we were likewise able to find both 
forms of organisms. But in its lower portion we found only the strep- 
tococci, which continued their way through the uterus by means of the 
lymphatics, and on reaching the peripheral surface gave rise to a perito- 
nitis. It would, therefore, appear that nature endeavors to confine the 
micro-organisms to the interior of the uterus by interposing between the 
necrotic layer and the deeper portions a wall of small-cell infiltration, 
which acts as an efficient filter when the micro-organisms are not viru- 
lent, but which fails to restrain them when they possess a marked degree 
of virulency. 

Parametritis. One of the most frequent complications of the uterine 
infection is parametritis, which is usually due to the propagation of the 
micro-organisms from the uterus by means of the lymphatics to the peri- 
uterine connective tissue. The first effect of the invasion of the connec- 
tive tissue by the micro-organisms is to cause a marked inflammatory 
oedema, but very little or no suppuration. In mild cases the infection 
goes only thus far, while in the more severe cases it rapidly spreads to 
the surrounding connective tissue and eventuates in abscess-formation. 
The infectious agents in severe cases follow the course of the lymphatics, 
either behind the peritoneum, where they may give rise to retroperi- 
toneal phlegmons, which in rare cases may extend up as high as the 
posterior mediastinum, while in other cases they follow the lymphatics, 
which extend into the anterior portion of the pelvis, when we have 
inflammatory phenomena occurring about the inguinal canal, and in some 



:~ i PATHOLOQ V OF THE PUERPERIUM. 

cases Following the i neotive tissue surrounding the greater ves.-els of 

the thigh, when it gives rise to phlegmasia alba dolens. 

Oooasionally the parametritic involvement has its origin from infected 
tear- about the eervix, hut in the vast majority of eases it is due to infec- 
tion from the uterine cavity. 

A- has already been pointed out, in a considerable number of cases 
the endometritic process extends into the uterine wall, and there gives 
rise to the various lesions of metritis, which may vary from small areas 
of small-cell infiltration to marked ahscess-fortnation. In the majority 
of cases, however, in which we meet with abscesses scattered through 
the uterine wall, we find that they are due to lymphatic involve- 
ment, and, as the lymphatic supply of the uterus is most marked just 
beneath the peritoneum, we find the abscesses most frequently in that 
situation. 

Salpingitis. In a certain proportion of cases the process extends 
directly from the uterine cavity to the Fallopian tubes, and there gives 
rise to the various inflammatory phenomena. In a small proportion of 
cases, however, the salpingitis is due to infection through the lymphatics, 
and not by continuity from the uterine cavity. In a certain number of 
cases w r e observe an oophoritis ; here the ovaries are enlarged to several 
times their usual size, and are very oedematous. The process may stop 
here or go on to abscess-formation, when we have to deal with a typical 
ovarian abscess. The ovarian infection in the vast majority of cases is 
due to lymphatic involvement, and is usually coincident with affections 
of the parametrium. In a small number of cases, however, the ovarian 
infection may be due to direct infection of a ruptured follicle by means 
of the peritonitic fluid. 

Peritonitis. In the vast majority of cases the fatal termination in 
puerperal infection is due to peritonitis. As we pointed out when con- 
sidering the histological changes in puerperal endometritis, the strepto- 
cocci or other infecting agents rapidly make their way from the interior 
of the uterus to its peritoneal surface by means of the lymphatics, and 
there give rise to peritonitis. This is the usual mode of infection; but 
in certain other cases, which, however, occur but rarely, the peritoneum 
is infected by pus which escapes from the Fallopian tubes, and in other 
cases by the rupture of parametritic or ovarian abscesses. But in none 
of the autopsies which the writer has performed upon women dead of 
puerperal fever has he observed a peritonitis which he could attribute 
to direct transmission through the tubes. 

Pyjemia. The pyaemic form of puerperal infection usually results 
from the infection of thrombi at the placental site and the subsequent 
inflammatory changes occurring in the veins. The thrombosis may be 
limited to a comparatively small area and be entirely within the uterine 
wall, or it may extend beyond the uterus, and we occasionally find all 
the pelvic vessels thrombosed up as high as the junction of the renal 
veins with the inferior vena cava. By the breaking down of the thrombi 
small particles escape into the circulation and are carried by the blood- 
current to various portions of the body, where they give rise to meta- 
static abscesses, from which apparently no portion of the body is exempt. 
In this form of puerperal infection we may find metastatic abscesses in 
all the internal organs, and frequently we find the synovial surfaces 



PUERPERAL INFECTION. 575 

affected, giving rise to swellings about the joints, which, if not promptly 
treated, lead to their complete destruction. 

In a number of other cases we notice blebs or bulla? appearing on 
various portions of the body, which are due to the same cause, and in 
whose contents we may readily demonstrate the offending micro-organ- 
ism. In most cases of pyaemia we find very little uterine involvement, 
and when death occurs it is due to the general exhaustion following a 
prolonged suppurative process, rather than to peritonitis, which is the 
usual cause of death in the other forms of infection. 

Phlegmasia Alba Dolens. As we pointed out when considering 
the question of parametritis, this affection is due to the extension of the 
parametritic process to the tissues surrounding the great vessels of the 
thigh by means of the lymphatics. The statement is frequently made 
that phlegmasia alba dolens is the result of thrombosis of the femoral 
vessels, but a moment's consideration will show that this is not the case, 
and that when thrombosis is observed it is secondary to the lymphatic 
involvement and not its cause. The consideration of the clinical picture 
will serve to substantiate this statement. If the swelling of the leg in 
this affection were due to thrombosis of the femoral vein, we would 
expect to observe it, at least in its early stages, about the foot and ankle; 
but we know that in cases of phlegmasia the swelling commences about 
the thigh, and only slowly makes its way downward. 

Etiology. From the consideration of the various bacteria concerned in 
puerperal infection, it is evident that we have to deal with the organisms 
with which we are familiar as causing wound-infection; and, generally 
speaking, we may say that puerperal infection is wound-infection, caused 
by the introduction of pathogenic organisms within the generative tract, 
either during labor or immediately after it. In other words, we have to 
deal with a direct infection from without, the infectious germs being 
brought to the woman by the hands, instruments, or any object which 
comes in contact with her generative organs. 

Puerperal infection is contact-infection, and this conception was first 
definitely enunciated by Semmelweiss 1 in 1847, in the following words: 
" I consider puerperal fever, not a single case excepted, as a resorption 
fever, caused by the resorption of a decomposed organic-animal material. 
The first result of the absorption is a change in the blood, and the exu- 
dations are the results of this change. The decomposed animal-organic 
material, which when resorbed causes childbed fever, is brought to the 
individual from without in the greatest majority of cases, and this is 
infection from without. These are the cases which represent the epi- 
demics of child-bed fever; these are the cases which can be prevented/' 

In the latter part of the last century puerperal fever began to be con- 
sidered as a contagious malady in England. This conception apparently 
originated with Thomas Kirkland, 2 of Ashby, in 1774, but was first 
clearly enunciated in 1795 by Gordon, of Aberdeen, in his treatise 
" On the Epidemic of Puerperal Fever, as it prevailed in Aberdeen 
from December, 1789, to March, 1792," in which he gave a table of 
77 cases which he had attended himself. 

1 Semmelweiss. Die Aetiologie der Begriff u. die Prophylaxis des Kindbettfiebers Pest. Wien u. 
Leipzig, 1861. 

2 Kirkland. Treatise on Childbed Fever, 1774. 



57G PATHOLOG ? OF THE PUEBPEBIUM, 

In this country the man who played the greatest part in introducing 
the conception or the contagious or infectious nature of the affection was 

Oliver Wendell Holmes, 1 who in L843 wrote an article on c> Puerperal 
Fever as a Private Pestilence," in which he clearly showed that it was 
a preventable affection, and owed its origin either to the accoucheur or 
midwife. I Lolmes's teachings, however, did not exert the influence which 
might have been expected from them; for they were opposed by the lead- 
in- obstetricians of the country, notably Meigs and Hodge, of Phila- 
delphia, Meigs stating that he preferred to consider puerperal fever as 
due to the workings of Providence, which lie could understand, rather 
than to an unknown infection of which he could form no conception. 

For many years the main theory in Europe as to the causation of puer- 
peral fever was that it was due to miasmatic or atmospheric influence. 
And this view continued until after the appearance of Semmelweiss's 
article in 1861, although in 1864 Hirsch, 3 after studying the matter from 
an historical stand-point, came to the conclusion that it was of infectious 
rather than of miasmatic origin. 

It was not, however, until Lister had introduced antiseptic methods 
into surgery and the use of bichloride of mercury was introduced into 
obstetrics by Stadtfelt, of Copenhagen, that the great mass of the pro- 
fession began to understand that puerperal fever was due to contact- 
infection, and could be prevented to a very great degree. After the 
bacteriological work of Pasteur 4 and his successors, and the constant 
finding of streptococci in fatal cases, the question was raised above all 
doubt, and at the present time no one doubts the infectious origin of these 
cases. 

Modes of External Infection. The most usual mode of infec- 
tion is by the hands of the obstetrician or the midwife, and no one who 
has observed the way in which the average medical man conducts a labor 
case can wonder that puerperal fever occasionally occurs. The introduc- 
tion of dirty instruments, as well as dirty hands, plays an important 
part in the production of the infection, and a source of infection which 
is frequently overlooked is due to copulation during the latter weeks of 
pregnancy. Contact with secretions from wounds of any kind also plays 
an important part in its production, and whether the purulent secretion 
be from.au external wound or anywhere within the body, the results will 
be the same. It is only necessary to recall in this connection the case 
of Dr. Rutter, of Philadelphia, who was followed wherever he went by 
an epidemic of puerperal fever, while his brother practitioners were prac- 
tically free from it. It appeared later that the source of infection in his 
cases was an ozsena, from which he was constantly infecting his hands. 

The disease is often due to wounds on the hands of the nurse, and 
many cases may be traced to bone-felons and other affections of the 
fingers, and not infreqently to a pustulous eczema on the hands. 

For many years it has been known that physicians attending cases of 
erysipelas, and then going to women in labor, frequently have to deal 
with puerperal infection, and one of the old ideas concerning the disease 

1 Holmes. Puerperal Fever as a Private Pestilence. Boston, 1865. 

- Meigs. Obstetrics : The Science and the Art. Second edition, 1852. 

s Hirsch. Historisch-pathologische Untersuchungen iiber Puerperalfieber. Erlangen, 1864. 

* Pasteur. Septicemie puerperale. Bull, de l'Acad. de Med., 1879, 260, 271. 



PUERPERAL INFECTION. 577 

was that it was identical with erysipelas, and it was not until bacteriology 
showed us that both erysipelas and most cases of puerperal infection are 
due to the streptococcus that this relation was understood. At the present 
time the majority of observers believe that there is no essential difference 
between the streptococcus erysipelatis of Fehleisen and the ordinary 
streptococcus pyogenes. It has frequently been observed that puerperal 
fever also occurs in the practice of those attending diphtheria and scarlet 
fever and occasionally typhoid cases. There is no essential relationship 
between these affections, but we know that in both diphtheria and scarlet 
fever we frequently meet with complications which are due to the strep- 
tococcus, and these streptococci are conveyed to the woman in labor. 

It is generally stated that air infection plays an important part in the 
production of puerperal infection, and many advise covering the external 
generative organs with an occlusive pad, to prevent the entry of air 
within the vagina, and thus avoid this source of infection. It appears 
to us, however, that air-infection is a very infrequent cause of the disease, 
if it ever occurs, and we cannot indorse the statements of Garrigues, 1 in 
his article on this subject in the American Text-book of Obstetric*, in 
which he attributed an epidemic of puerperal fever in the New York 
Lying-in Hospital to the presence of a dead rat in the cellar. It is 
much more probable that the epidemic was due to imperfect hand-disin- 
fection on the part of his assistants, or to the introduction of pathogenic 
organisms within the vagina by the hands of the patients themselves. 
In England, and to a slight extent in this country, sewer-gas is believed 
to play a prominent part in the production of puerperal infection, and 
at a meeting of the health officers of Great Britain in London, some years 
ago, at which the writer was present, a prominent medical man stated that 
the first duty of the obstetrician on visiting the house of his patient was 
to inspect the sanitary arrangements instead of examining the patient. 
And the writer was informed by good authority that after the serious 
illness of a prominent woman from puerperal infection, in one of the 
smaller towns of England, the entire sewerage system of the town was 
torn up to discover the leak from which the sewer-gas escaped, which was 
supposed to have been the cause of the disease. There can be no doubt 
that the danger of infection from the air or from sewer-gas is greatly 
exaggerated, and it will be spoken of less and less frequently as medical 
men become better versed in the technique of rigorous hand-disinfection. 

To show what an accurate conception Semmelweiss 2 had of the various 
modes of contact-infection, it may be interesting to quote what he says in 
this connection : " The bearer of the decomposed animal-organic material 
is the examining-finger, the operating-hand, instruments, bedclothes, the 
atmospheric air, sponges, the hands of the midwife or nurses which come 
in contact with the excrement of women sick with puerperal fever, and 
after that handle pregnant and parturient women. In other words, the 
bearer of the decomposed animal-organic material is anything which is 
soiled by a decomposed animal-organic material and comes in contact 
with the genitals of these patients. " 

Auto-infection. Every one at the present time believes that the 

1 Garrigues. Puerperal Infection. American Text-book of Obstetrics, 1895, 683-734. 

2 Semmelweiss. Die Aetiologie der Begriflf u. die Prophylaxis des Kindbettfiebers Pest. Wein u. 
Leipzig, 1861. 

37 



578 PATHOLOGY OF Tin-: PUERPEBIUM. 

vast majority of cases of infection are the result of the introduction 
within the generative organs of the pregnant or parturient woman of 
pathogenies micro-organisms from without, by means of the examining- 

tinger or in sonic other way. But many also believe that in a certain 

number of oases the infection is not due to the introduction of organ- 
isms from without, but owes its origin to micro-organisms which were 
already within the woman before the onset of labor. To infections 
arising in this way the term "auto-infection" is applied. The term 
originated with Semmelweiss, 1 who stated : " In rare cases the decom- 
posed animal material, which causes childbed fever when absorbed, is 
produced within the patient herself. These are the cases of auto-infec- 
tion, and cannot be prevented." 

With the enthusiasm which attended the introduction of antiseptic 
methods into midwifery, the conception of auto-infection was lost sight 
of for a time, and it was only when the statistics of well-conducted lying- 
in establishments showed that a certain amount of infection occurred in 
spite of the rigorous application of antiseptic principles that the idea of 
auto-infection was rehabilitated by Ahlfeld 2 and Kaltenbach. 3 Of course, 
with the recognition of the fact that puerperal fever is due to certain 
micro-organisms, the definition introduced by Semmelweiss 4 fell to the 
ground, as it is not possible for the organisms to originate spontaneously 
within the body of the woman. The conception was then introduced 
by Kaltenbach 5 that in a considerable number of cases pathogenic organ- 
isms are normally found in the vaginae of pregnant women, which may be 
introduced into the uterus by the introduction of a perfectly sterile finger 
within the vagina. It is apparent in such cases that we do not have to 
deal with auto-infection in the strict sense of the word, and much con- 
fusion would have been avoided had the term indirect infection been 
substituted for it; because the micro-organisms must have been intro- 
duced into the vagina at some period of life, and the question simply 
resolves itself into one of time. Certain observers, notably Slavjansky 6 
and Szabo, 7 state that auto-infection, even in this modified sense, is not 
possible, and that all cases of puerperal infection are due to the intro- 
duction of pathogenic micro-organisms at the time of labor. 

This appears to be an extreme view, and the question must stand or 
fall with the results of the bacteriological examination of the generative 
organs in the pregnant and non-pregnant state. If careful bacteriological 
examination shows that pathogenic micro-organisms are absent from the 
uteri and the vaginae of pregnant women, we must abandon all idea of 
auto-infection. If, on the other hand, it can be shown that pathogenic 
organisms can be demonstrated in the vaginae and uteri of apparently 
healthy women before and during pregnancy, we shall be forced, no 
matter what our preconceived ideas may be, to admit the possibility 

1 Semmelweiss. Op. cit. 

2 Ahlfeld. Beitrage zur Lehre von Resorptionsfieber im Wochenbett und von der Selbstinfektion. 
Berichte und Arbeiten, 1883, i. 165. Beitrag zur Lehre der Selbstinfektion. Cent. f. Gyn., 1887, 
729. 

3 Kaltenbach Zur Atisepsis in der Geburtshiilfe. Volkmann's Sammlung klin. Vortrage, Nr. 295. 
Ueber Selbstinfektion. Verh. deutschen Ges. f. Gyn., Freiburg, 1889. 

* Semmelweiss. Op. cit. 

6 Kaltenbach. Ueber Selbstinfektion. Verh. deutschen. Ges. f. Gyn., Freiburg. 1889. 

c Slavjansky. Die Antiseptik in der Geburtshiilfe. Verh. de x. internat. med. Congresses, 1891, iii. 
Abth. vii. 1. 

7 v. Szabo. Zur Frage der Selbstinfektion. Arch. f. Gyn., 1889, xxxvi. 77-101. 



PUERPERAL INFECTION. 579 

of auto-infection, and to believe that cases of puerperal fever are not 
all clue to infection from without. 

All bacteriological observers are united in claiming that the body of 
the normal uterus both in the pregnant and the non-pregnant condition 
is free from micro-organisms. This has been amply demonstrated by 
the observations of Goenner, 1 Doederlein, 2 Winter, 3 Ott, 4 Czerniewski, 5 
Stroganoff", 6 Kronig and Menge; 7 Strauss and Sanchez-Toledo 8 have 
demonstrated the same in the lower animals. When we come to consider 
the bacterial contents of the cervix in the healthy woman we find that 
the observations are not so uniform. Thus, we find that Winter, 9 Doe- 
derlein, 10 and other observers state that in the majority of instances w r e 
may find micro-organisms within the cervix; while, on the other hand, 
Stroganoff 11 states that iri 74 per cent, of the cases the cervix is sterile, 
and Goebel 12 made the same observation in 29 out of 30 cases. Goenner 13 
and Walthard, 14 on the other hand, state that the cervix is normally 
sterile in all cases; and Walthard V 5 work seems to throw a definite light 
upon the snbject and explains the conflicting results of previous observers. 
He found that cultures taken from the lowest portion of the cervical 
canal contained identically the same organisms as does the vagina; but, 
as we go up a short distance into the canal, the organisms become fewer 
and fewer in number, and disappear altogether about one-third of the 
way up. Walthard 16 believes that the mucous secretion of the cervix, 
which fills it as a plug during pregnancy, plays a marked part in prevent- 
ing the increase of micro-organisms, and he has clearly shown that it 
offers a medium which is absolutely unfavorable for their growth and 
development. 

It would appear, then, that the observers who have noted bacterial 
contents in the cervix obtained their secretion from the lower part of 
the cervical canal, while those who obtained negative results obtained 
it from higher up. It would appear, therefore, from the consideration of 
the bacteriological work which has been done upon the bacterial contents 
of the uterus and cervix, that they may be considered as, practically, 
if not absolutely, sterile, and that they, therefore, offer no possibility 
for the occurrence of auto- or indirect infection. The question, accord- 

1 Goenner. Ueber Mikroorganismen in Sekrete der weibliehen Genitalien wahrend der Schwanger- 
schaft und bei puerperalen Erkrankungen. Cent. f. Gyn., 1887. 444. 

2 Doederlein. Untersuchung iiber das Vorkomen von Spaltpilzen in den Lochien des Uterus und 
der Vagina gesunder und kranker Wiichnerrinnen. Arch. f. Gyn., 1887, xxxi. 412. 

3 Winter. Die Mikroorganismen im Genitalkanal der gesunden Fraun. Zeit. f. Geb. u. Gyn., 
1888. xiv. 443. 

4 Ott. Zur Bakteriologie der Lochien. Arch. f. Gyn., 1888, xxxii. 436. 

5 Czerniewski. Zur Frage von den puerperalen Erkrankungen. Eine bakteriologische Studie. 
Arch. f. Gyn.. 1888, xxxiii. 73. 

6 Stroganoff. Bakteriologische Untersuchungen des weibliehen Genitalschlauches. Cent. f. Gyn., 
1895, 935. Bakteriologische Untersuchungen des Genitalkanalesbeim Weibe in verscheidenen Perioden 
ihres Lebens. Monats. f. Geb. u. Gyn., 1895, ii. 365-369, 494-504. 

7 Kronig. Scheidensekret-untersuchungen bei 100 Schwangeren. Aseptik in der Geburtshtilfe. 
Cent. f. Gyn.. 1894, 3-10. 

8 Strauss and Sanchez-Toledo. Septicemie puerperale experimentale. Nouv. Arch, d'obstet. et de 
gyn., 1889, cv. 277-295. 

9 Winter. Die Mikroorganismen in Genitalkanal der gesunden Fraun. Zeit. f. Geb. u. Gyn., 1888, 
xiv. 443. 

10 Doederlein. Untersuchungen liber das Vorkomen von Spaltpilzen in den Lochien des Uterus 
und der Vagina gesunder und kranker Wbchnerrinnen. Arch. f. Gyn., 1887, xxxi. 412. 

11 Stroganoff. Op. cit. 

12 Goebel. Der Bakteriengehalt der Cervix. Cent, f. Gyn., 1896, 84. 

*3 Goenner. Ueber Mikroorganismen in Sekrete der weibliehen Genitalien wahrend der Schwanger- 
schaft und bei puerperalen Erkrankungen. Cent. f. Gyn., 1887, 444. 

14 Walthard. Bakteriologische Untersuchungen des weibliehen Genitalsecretes in Graviditats und 
im Puerperium. Arch. f. Gyn., 1895, xlviii. 201-269. 

15 Walthard. Op. cit. 

16 Walthard. Op. cit. 



580 PATHOLOGY OF THE PUERPERIUM. 

inglj, resolves itself Into the demonstration of pathogenic organisms 
within the healthy vagina, and with their demonstration the question 
of auto-infection must be generally accepted <>r absolutely abandoned. 

AhltVM, 1 in all his articles on this subject, states " that the vagina is 
swarming with various varieties of pathogenic organisms, and the only 
way to pi-event auto-infection is to disinfect the vagina thoroughly in 

everv case by antiseptic douches. On the other hand, the bacteriological 

work of Goenner, 2 Thomen, 3 Samschio, 4 E£rdnig and Menge 3 appears t<> 
show that no pathogenic micro-organisms can be found in the vagina 
of pregnant women, with the exception of the gonococcus. A Large 

number of observers, however, state as the result of careful bacterio- 
logical work that pathogenic micro-organisms may be found in the vagina 
in a varying percentage of cases; thus, Winter 9 demonstrated them in 50 
percent, of his cases; Steffeck 7 in 47 percent., and pathogenic organisms 
have been found in a lesser percentage by Doederlein, 8 Widal,' 1 Witte, 10 
Burguburu, 11 Burchhardt/ 2 AVilliams, 13 Stroganoff, u Mironow, 1 ' Walt- 
hard, 16 Vahle, 17 and Kottmann. 

Thus, it is apparent that the bacteriological work ou the one hand 
appears to prove that auto-infection is absolutely impossible, while on 
the other hand it shows that it is possible in a varying percentage of 
cases, reaching as high as 50 per cent, in Winter's 18 observations, and 
47 per cent, in Steffeck's. 19 

The discrepancy between the bacteriological work of the various ob- 
servers was apparently solved in 1892 with the appearance of Doeder- 
lein's 20 work on the vaginal secretion, in which he pointed out that the 
normal vaginal secretion was a thick, creamy, or even cheese-like mate- 
rial, of a whitish color, and distinctly acid, reaction. Microscopically it 

1 Ahlfeld. Beitrage zur Lehre von Resorptionsfieber im Wochenhett und von der Selbstinfektion. 
Berichte und Arbeiten, 1883, i. 165. Beitrag zur Lebre der Selbstinfektion. Cent. f. Gyn., 1887, 729. 
Beitrage zur Lehre vora Resorptionsfieber in der Geburt und im Wocbenbette und vjii der Seibstin- 
fektlon Zeit. f. Geb. u. Gyn. ,"1893, xxvii. 46(5-519. 

2 Goenner. Ueber Mikroorganismen im Sekrete der weiblicben Genitalien wahrend der Sch wanger- 
schaft und bei puerperalen Erkrankungen. Cent. f. Gyn., 18S7, 411. 

s Thomen. Bakteriologische Untersuchungen normaler Lochien und der Vagino und Cervix, 
Schwangerer. Arch. f. Gyn., 1889, xxxvi. 231. 

4 Samschin. Ueber das Vnrkomen von Eiterstaphylococcen in den Genitalien von gesunder Frauen 
Deutsche med. Wochen., 1890, 332. 

5 Kriinig. Seheidensekret-untersuchungen bei 100 Schwangeren. Aseptik in der Geburtshiilfe. 
Cent. f. Gyn., 1894, 3-10. 

6 Winter. Die Mikroorganismen in Genitalkanal der gesunden Fraun. Zeit. f. Geb. u. Gyn., 
1888, xiv. 443. 

7 Steffeck. Bakteriologische Begriindung der Selbstinfektion. Zeit. f. Geb. u. Gyn., 1890, xx. 330. 

8 Doederlein. Untersuchungen liber das Vorkomeu von Spaltpilzen in den Lochien des Uterus und 
der Vagina gesunder und kranker Wochnerriunen. Arch. f. Gyn.. 18S7, xxxi. 412. Klinisehes und 
Bakteriologisches liber eine Puerperalfieber Epidemie. Arch. f. Gyn., 1891, xl. 99. Das Scheiden- 
sekret. und seines Bedeutung fur das Puerperalfieber. Leipzig, 1892. 

9 Widal. Etude sur l'infection puerperale. These de Paris, 1889. 

10 Witte. Bakteriologische Untersuchnngshefunde bei path. Znstande in weibl. Genitalapparat. 
rait besonderer Beuchsichtigung der Eitererreger. Zeit. f. Geb. u. Gyn., 1892, xxv. 1. 

11 Burguburu. Zur Bakteriologie des Vaginalsekretes Schwangeren. Arch. f. exper. Path, und 
Pharmak., Nov. 1892, xxx. 

'- Burchhardt. Ueber den Einfluss der Scheidenbakterien auf dem Verlauf des Wochenbettes. Arch, 
f. Gyn., 1893. xlv. 71-94. 

w Williams. Puerperal Infection Considered from a Bacteriological Point of View, with Special 
Reference to the Question of Auto-infection. Amer. Journ. Med. Sci., July, 1893. 

14 Stroganoff. Bakteriologische Untersuchungen des Genital kanales beim Weibe in verscheidenen 
Perioden ihres Lebens. Monats. f. Geb. u. Gyn., 1895, ii. 365-394, 494-501. 

15 Mironow. Ueber die Ursachen der puerperalen Erkrankungen. D. I. Charkow, 1889. Referat. 
Cent. f. Gyn., 1891. 678-80. 

10 Walthard. Bakteriologische Untersuchungen desweiblichen Genitalsekretes in Gravitate undim 
Puerperium. Arch. f. Gyn., 1895, xlviii. 201-269. 

17 Vahle. Ueber das Vorkomeu von Streptococcen in der Scheide Gebiirender. Zeit. f. Geb. u. Gyn., 
1896, xxxv. 192-215. 

18 Winter. Die Mikroorganismen im Genitalkanal der gesunden Fraun. Zeit. f. Geb. u. Gyn., 
1888. xiv. 443. 

>9 Steffeck. Bakteriologische Begriindung der Selbstinfektion. Zeit. f. Geb. u. Gyn., 1890, xx. 339. 
20 Doederlein. Das Scheidensekret. und seines Bedeutung fur das Puerperalfieber. Leipzig, 1892. 



PUERPERAL INFECTION. 581 

contained epithelial cells, a large number of tolerably long bacilli, and 
now and then a few yeast fungi. It contained absolutely no pathogenic 
micro-organisms and offered absolutely no support for the doctrine of 
auto-infection. On the other hand, in a certain proportion of cases he 
found a very different secretion which he designated as pathological. 
This was a fluid, more or less purulent secretion, generally of a yellowish 
color, and occasionally containing gas bubbles. In it he found large 
numbers of leucocytes, many micro-organisms of various kinds, and in 
a few cases streptococci. The reaction of the pathological secretion was 
frequently altered, it was less acid than normal, in some cases neutral, 
and in a few cases even alkaline. This work was based upon the exami- 
nation of 190 cases, 55.3 per cent, of which presented normal, and 44.6 
per cent, pathological secretion. In 10 per cent, of the pathological 
secretions he was able to cultivate the streptococcus, which in one-half 
of the cases proved virulent when inoculated into animals. It accord- 
ingly appeared that auto-infection could not possibly occur in women 
with normal secretion, and any rise of temperature in such cases was due 
to the introduction of pathogenic micro-organisms from without by the 
examining-finger or in some other way; whereas 10 per cent, of the 
pathological cases presented abundant theoretical facilities for auto-infec- 
tion. He therefore concluded that vaginal examination with a thoroughly 
disinfected fiuger was absolutely harmless in the first class of cases; while 
in the second class, no matter how carefully the finger might be disin- 
fected, the danger of auto-infection could not be avoided. And he 
therefore recommended that we should reserve the prophylactic vaginal 
douche for the second class of cases, and dispense w r ith it altogether in 
the first. 

The work of Doederlein 1 was soon confirmed by Burguburu, 2 Burch- 
hardt, 3 and the writer. 4 Burguburu' s 5 work was based upon 12 cases, 
in one-third of which he cultivated pathogenic micro-organisms, and in 
one case he obtained streptococci. 

Burchhardt' s work was based on 116 cases, in 59 per cent, of which 
the secretion was normal, according to the criteria laid down by Doeder- 
lein. 7 He also examined his cases with regard to the effect of the char- 
acter of the secretion upon the temperature during the puerperium, and 
found that the women who possessed normal secretions presented a rise 
of temperature in 23 per cent, of the cases, while in those with pathological 
secretions abnormal puerperia occurred in 50 per cent. The writer's 
work 8 was based upon the examination of 15 cases, in 3 of which (20 
per cent.) he was able to isolate streptococci, and in 5 other cases to 
demonstrate the presence of various forms of staphylococci. This work, 
in combination with that of Doederlein, 9 appeared to settle the ques- 
tion; but within a few months contrary observations were reported, 
which have materially weakened the distinctions brought forward by 
Doederlein and the observers who agree with him. 

1 Doederlein. Op. cit. 

2 Burguburu. Zur Bakteriologie des Vaginalsekretes Schwangeren. Arch. f. exper. Path, und 
Pharmak., Nov. 1892, xxx. 

a Burchhardt. Ueber den Einfluss der Scheidenbakterien auf dem Verlauf des Wochenbettes. 
Arch. f. Gvn., 1893, xlv. 71-94. 
* Williams. Op. cit. 5 Burguburu. Op. cit. 

e Burchhardt. Op, cit. 7 Doederlein. Op. cit. 

s Williams. Op. cit. 9 Doederlein. Op. cit. 



582 PATHOLOGY OF THE PUEBPEBIUM. 

E£ronig and Menge, 1 who Buoceeded Doederlein in the bacteriological 
work in the Leipzig Frauen-Klinik, came to exactly opposite conclusions. 
They stated that they could make no distinction between the normal and 

abnormal vaginal secretion, and stated that in all their experience, which 
was based noon some hundreds of cases, they had never met with a seere- 
tion which presented a neutral or even amphoteric reaction. But, more 
important than this, they stated that no pathogenic micro-organisms with 
the exception of the g fflOCOCCUS could be found in the vaginal secre- 
tion, whether normal or pathological (according to Doederlein), and, 
therefore, concluded that the vaginal secretion offered absolutely no pos- 
sibility for the production of auto-infection. 

When they examined their cases in reference to the effect of the nor- 
mal and pathological secretion of Doederlein 2 upon the temperature 
during the puerperia, they arrived at results diametrically opposed to 
those of Burchhardt, and in 103 women who had not been examined 
internally, 59 of whom presented pathological and 44 normal secretions 
according to Doederlein, 31 per cent, of the former and 45 per cent, of 
the latter presented rises of temperature during the lying-in period. 
They, therefore, denied in toto the conclusions arrived, at by Doederlein 
and those who believed that they could substantiate his results, ami 
stated that the frequency with which pathogenic micro-organisms were 
found by these observers was due to errors of technique, and that were 
they to adopt their methods in obtaining the vaginal secretion for exami- 
nation they would in all probability come to the same conclusion. 

Following the work of Menge and Kronig, 3 a very thorough article 
appeared from Walthard, 4 who based his work upon 100 cases observed 
in Berne, where he found streptococci in the vaginal secretion in 27 per 
cent, of the cases, and thus apparently confirmed the work of those who 
believed that there was a definite foundation for the doctrine of auto- 
infection in at least a certain number of cases. He stated that 43 per 
cent, of them agreed macroscopically with Doederlein' s normal secretion; 
but when he came to examine the cultures obtained from them he found 
streptococci in some 16 per cent, of the cases, and accordingly concluded 
that the macro- and microscopic characteristics as defined by Doederlein 
are not sufficient to allow us to differentiate between the two groups of 
secretion. 

The last observer to busy himself with this line of work is Yahle, 5 
of Marburg, who examined the secretions of 30 pregnant women, and 
found that 10 per cent, of them contained streptococci. He then exam- 
ined a series of 60 women in labor, and found that 25 per cent, of them 
presented streptococci in the vaginal secretion. His work, however, 
must be accepted with considerable hesitation, as it is not free from errors 
of technique, for he obtained the secretion from the women in labor by 
the introduction of a sterilized finger, from which the cultures were 
made directly. 

It would thus appear, in spite of the bacteriological work which has 

1 Kronig. Scheidensekret-untersuchungen bei 100 Schwangeren. Aseptik in der Geburtshiilfe. 
Cent. f. Gyn , 1894, 3-10 

- Doederlein. Op. cit. 3 Kriinig. Op. cit. 

* Walthard. Bakteriologische Untersuchungen des weiblicben Genitalseeretes in Graviditate und 
im Puerperium. Arch. f. Gyn., 1895, xlviii. 201-269. 

5 Vahle. Ueber das Vorkbrnen von Streptococcen in der Scbeide Gebiirender. Zeit. f. Geb. u. Gyn., 
1896, xxxv. 192-215. 



PUERPERAL INFECTION. 583 

thus far been done on the subject, that we are as far as ever from a scien- 
tific solution of the question — the one set of observers showing conclu- 
sively by their work that auto-infection is possible in a certain number 
of cases, while Menge and Kronig 1 absolutely deny the possibility of its 
occurrence. 

It would appear that there has probably been a source of error in all 
the work which has been done up to this time, except that of Menge and 
Kronig, 2 for all the observers except them have obtained the secretion 
for examination by the introduction of a sterilized speculum into the 
vagina, and by removing the secretion which lay beyond it with the 
platinum needle. And it is possible in this manner that a certain number 
of pathogenic micro-organisms may have been introduced from without; 
for it is well known that the labia abound with them, and it is impos- 
sible to introduce a speculum into the vagina without bringing it in con- 
tact with them. 

Kronig and Menge, 3 on the other hand, obtained their secretion by 
spreading the labia widely apart with the fingers and then introducing 
into the vagina a glass or metal tube 3-4 mm. in diameter in such a way 
as absolutely to avoid contact with the labia, and, therefore, to preclude 
any chance of contamination from without. 

In view of the contradictory results of the various investigations, the 
writer determined to repeat his work upon a larger number of cases, fol- 
lowing as closely as possible the methods of Kronig and Menge, and in 
May, 1898, he reported to the American Gynecological Society the results 
of the examination of 92 cases. 

In none of them did he find the streptococcus or staphylococcus aureus, 
but in six cases he did find the staphylococcus epidermidis albus. Whether 
the latter really existed in the vagina or were due to contamination is 
open to doubt; but as they are never found in severe cases of puerperal 
infection, their presence in the vaginal secretion is a matter of indiffer- 
ence as far as the question of auto-infection is concerned. 

He accordingly stated that he could confirm Kronig' s observations as 
to the absence of pyogenic cocci from the vaginal secretion, and believed 
that auto-infection due to them could not occur, although he was not pre- 
pared to state that it might not occasionally occur with other bacteria, 
especially in some of the cases of so-called putrefactive endometritis. 

These conclusions are absolutely contradictory to those which the writer 
formed five years ago, when he was able to confirm Doederlein's state- 
ments by finding streptococci in 20 per cent, of his cases. And the only 
possible explanation for this difference must lie in the manner in which 
the vaginal secretion was obtained for examination in the two series of 
cases, as all the other conditions were identical. In the first series he 
obtained the secretion by means of a sterilized glass speculum; but in 
the latter series by means of Menge' s tube. 

It would, therefore, appear that in introducing the speculum we carried 
into the vagina a number of bacteria from the margin of the hymen and 
the inner surface of the labia minora, with which the speculum had come 
in contact; while we avoided such contact when the tube was employed, 
and thus obtained the secretion absolutely free from contamination. 

1 Kronig. Op. cit. 2 Kronig. Op. cit. 3 Kronig. Op. cit. 



584 PATHOLOGY OF THE PUEBPERIUM. 

This baa been placed beyond all doubt by the examination of twenty- 
five additional cases, from each of which we made three sets of cultures 
— first, from the hymen and the inner surface of the labia minora; sec- 
ond, from vaginal secretion obtained by means of Menge's tube, and 
lastly, from vaginal secretion obtained by means of a sterilized speculum. 

( !ultures from the vulva showed the presence of pyogenic cocci or colon 
bacilli ill twenty cases (80 percent.); cultures from the vaginal secretion 
obtained by means of the speculum showed the same organism in twelve; 

cases, or 18 |>er cent. ; while they were entirely absent when the secretion 
had been obtained by means of Menge's tube, which was absolutely 
sterile, on agar plates, in 70 per cent, of the cases. 

These experiments show conclusively that the vaginal secretion, when 
obtained without contamination, is absolutely free from the pyogenic 
cocci, but that such bacteria are carried up into the vagina from the 
vulva in nearly one-half the cases in which we attempt to obtain the 
secretion by means of a sterilized glass speculum. 

An interesting fact in connection with the question of auto-infection 
is that those who believe most firmly in the possibility of auto-infection 
and resort to the employment of the prophylactic vaginal douche for 
the destruction of the organisms which are in the vagina, present far 
more unfavorable statistics than those who take the opposite view. 
Thus, for example, Ahlfeld, 1 who is the most pronounced believer in 
auto-infection, finds that 38 per cent, of his cases, even after being proph- 
ylactically douched, present a rise of temperature in the puerperium. 

The results of Kaltenbach, who, as a consistent believer in auto-infec- 
tion, resorted to the routine employment of the prophylactic vaginal 
douche, have been very materially improved since Fehling 2 has taken 
charge of the clinic in Halle, and discontinued its use. The results of 
Leopold 3 and Hermann, 4 w T ho do not use the douche at all, show constant 
improvement with the increasing care with which objective asepsis is 
carried out. 

In a recent article by Jewett 5 the opinions of most of the American 
obstetricians upon this subject are quoted, and it appears that the ten- 
dency is in the same direction, and that, while a certain number of them 
believe theoretically in auto-infection, they practically act as if its occur- 
rence was impossible. 

Frequency. It is very difficult to make accurate statements as to the 
frequency of puerperal infection, especially when it occurs outside of 
hospital practice; for the consideration of the vital statistics of the health 
officers of the various cities fails to give any idea as to the frequency 

1 Ahlfeld. Beitrage zur Lehre vora Resorptionsfieber in der Geburt und Wocheubette und von der 
Selb<tinfektion. Zeit. f. Geb. n. Gyn.. 1893, xxvii. 466-519. 

2 Fehling. Ueber die Eikrankun'gsziffern der Entibindungshauser. Deutsche med. Wochen., 1896, 
426. 

s Leopold. Ueber die Wochenbetten von nicht untersuchten und nicht ausgespiilten Gebarenden. 
Verh. deutsche Ges. f. Gyn., Freiburg, 1889. Dritter Beitrag zur Verhiitung des Kindbettfiebers. 
Arch. f. Gyu., 1889, xxxv. 149-162. Versrleichende Untersuchungen liber die Entbehrlichkeit der 
Scheiden-ausspiilungen bei ganz normalen Geburten und iiber die sngenannteSelbstinfektion. Arch, 
f. Gyn., 1894, xMi. 580-635. Ueber die Entbehrlichkeit der Scheidenausspiilungen und Auswaschun- 
gen bei redelm.-issigen Geburten und iiber die griisstmiigliche Verwerthung der ousseren UntersuchUng 
in der Geburtshulfe. Arch. f. Gyn.. 1891, xl. 439. 

4 Mermann. Zur Antisepsis in der Geburtshulfe. Cent. f. Gvn., 1887, 539. Die Entbehrlichkeit und 
Gefahren innerer Desinfektion normalen Geburten. Verb." deutsche Ges. f. Gvn.. Freiburg, 1889. 
Fiinfter Bericht iiber 200 Geburten ohneinnere Desinfektion. Cent. f. Gvn., 1893, 177. Sechster Bericht 
liber Geburten ohne innere Desinfektion. Cent. f. Gvn., 1894, 786. 

5 Jewett. The Question ot Puerperal Self-infection. Arner. Gyn. and Obstet. Journ., 1896, viii. 
417-^29. 



PUERPERAL INFECTION. 585 

with which the disease occurs, because the vast majority of deaths from 
puerperal infection are not reported as such, but as malaria, typhoid 
fever, pneumonia, etc. ; for the laity have learned that puerperal fever 
is a preventable affection, and when it occurs are inclined to lay the 
blame upon the physician in charge of the case, which he usually 
attempts to shirk by stating that death was due to some other affection. 

That the tables prepared by the various health officers give no idea as 
to the frequency of death from puerperal infection is made very evident 
by the statement of Reynolds, 1 who in 1893 attempted to write an 
article upon the prevalence of puerperal fever in Boston. But on look- 
ing over the statistics furnished by the health office he found that he had 
seen during that year, if the reports of the department were accurate, 
more than one-fourth of all the cases of this character in Boston. Rey- 
nolds himself saw 28 cases in hospital and consultation practice, with 7 
deaths; and it is evident that many more than 28 women died from the 
affection in Boston during that time. 

Since the introduction of antiseptic and aseptic methods into midwifery 
the mortality from puerperal infection has diminished very markedly in 
hospital practice. In the old maternity of Paris and in the lying-in 
hospital of Vienna it was not at all infrequent to find years in which 
the mortality from this affection varied between 10 and 15 per cent, of 
all the women entering the institution. Just before the introduction of 
antiseptic methods the frightful mortality occurring in such institutions 
attracted the attention of the public at large, and steps were being insti- 
tuted to abolish them as a menace to public health. With the introduc- 
tion of aseptic methods, however, all this is changed, and in well-regulated 
lying-in institutions the mortality from sepsis is usually only a fraction, 
and a small fraction at that, of 1 per cent. And at present, in the dis- 
cussions on puerperal infection, at least as far as hospitals are concerned, 
the question is one of percentage of morbidity, namely, the number of 
patients whose temperature during the puerperium rises above 38° C. or 
100.4° F., rather than of mortality. 

On the other hand, in private practice it is questionable whether the 
results of to-day are materially better than before the introduction of 
antiseptic methods. At the present time we rarely hear of epidemics of 
puerperal infection such as occurred previously, and which we find men- 
tioned in the historical work of Hirsch, 2 who gives us the particulars of 
216 epidemics occurring between the years 1652 and 1862. 

It would appear to us that puerperal infection is almost as frequent in 
private practice now as fifteen years ago, for the reason that the doctrines 
of asepsis have not yet permeated the rank and file of medical men, 
much less those of the midwives, in whose hands a very large proportion 
of all obstetrical cases occur. 

Bacon, 3 in a recent article, based upon the records of the health depart- 
ment of Chicago, shows that puerperal infection still plays a very promi- 
nent part in the death list. His statistics embrace the last forty years, 
during which period he estimates that 12.75 per cent, of all women dying 

1 Reynolds. The Frequency of Puerperal Sepsis in Massachusetts, etc. Boston Med. and Surg. 
Journ., cxxxi. 153-155. 

2 Hirsch. Historisch-pathologische Untersuchungen iiber Puerperalfleber. Erlangen, 1864. 

3 Bacon. The Mortality from Puerperal Infection in Chicago. Amer. Gvn. and Obst. Journ., 1896. 
viii. 429-446. 



PATHOLOGY OF THE PUEBPEBIUM. 

between the ages of twenty and fifty years succumbed to puerperal sepsis. 
In 1873, 20 per cent, of all women dying between these ages succumbed 
to the affection. Since then the mortality has gradually fallen, reaching 

(J per cent, iii 1 <Si)2. But during the last five years the mortality lias 
remained almost constant, being 7. '•) percent, in the year 18 95. These 

results are substantiated by those of Ingerslev,' who states thai even at 
the present time in Denmark puerperal infection is the most frequent 
cause <>f death in women between the ages of twenty and fifty years, 
with the single exception of tuberculosis. 

Boxall,* in an article on the mortality of childbirth, which appeared 
in the Lancet in 181):$, has tabulated the statistics of the Registrar Gen- 
eral's Office for forty-five years — that is, from 1847 to 181)2. His tables 
give the average mortality for every 100,000 confinements for England 
and Wales, for London, and for the provinces, and in this way he is able 
to accentuate the difference between the results in London itself and the 
counties. He then divided his statistics into those occurring before 1860 
and those occurring since 1880, so as to permit of comparison between 
the results obtained in the pre-antiseptic and antiseptic eras. And he 
found that in London the deaths in childbirth from all causes had decreased 
since 1880 from 54 to 37 deaths per 100,000; but that this decrease was 
due almost entirely to the decrease in the number of deaths from the 
accidents of childbirth, and to a better and prompter application of 
instrumental procedures; while in the counties the death-rate from all 
causes is nearly as great as it was thirty years ago, thus showing that 
the application of antiseptic and aseptic methods had not permeated the 
ranks of the profession, and that outside of the lying-in hospitals the 
results are as bad to-day as twenty or even forty-five years ago. 

In considering the frequency of puerperal infection we should not be 
guided altogether by the consideration of its mortality, for the largest 
proportion of these cases do not result in death. But any one who has 
had an opportunity of observing a number of gynecological cases cannot 
fail to be impressed with the very large proportion of cases coming into 
his hands which owe their origin to febrile affections during the puerpe- 
riurn, which are preventable for the great part, and are due to the neglect 
of aseptic precaution on the part of the physicians in charge. 

Symptomatology. According to the statements of Labadie-Lagrave 
and Basset, 3 we rarely meet with the virulent forms of puerperal infec- 
tion with which our predecessors had to deal. And they consider that in 
the vast majority of cases we meet with attenuated forms of the affection, 
whose modified course, in all probability, is due to the more or less rigor- 
ous application of antiseptic principles, which results in a diminution of 
the virulence of the offending organisms. According to them, in the 
cases of sepsis without definite localization, the symptoms are not so 
severe as formerly, and a considerable number of patients recover; while 
in other cases the infection does not make its appearance until the latter 
part of the puerperium, and then only in a comparatively mild form. 

As stated when considering the pathological anatomy of puerperal 

1 Ingerslev. Die Sterblichkeit an Wochenbettfieber in Danemark und die Bedeutnng der Antiseptik 
fur disselle. Zeit. f. Geb. u. Gyn.. 1893, xxvi. 443. 

-' Boxall. The Mortality of Childbirth. Lancet, 1893. ii 9-15. 

s Labadie-La grave and Basset. La sc'ptioomie nuerperale attenuee (etude bacteriologique). Con- 
grSs period, internat. de gyn. et d'obstet., 1892. Brux., 1894, i. 319-325. 



PUERPERAL INFECTION. 587 

infection, its most usual form is an endometritis, which may be either of 
the septic or putrid variety. The symptoms vary considerably according 
to the form with which we have to deal, and we shall first consider those 
of the septic variety. 

In the cases of septic endometritis everything goes smoothly for the 
first three or four days of the puerperium, when our patient, who thus 
far has done perfectly well, suddenly experiences more or less malaise, 
possibly has a headache, and toward the end of the third or fourth day 
a chill, after which the temperature rises to 103° or more. Generally 
the chill occurs but once, while the temperature remains constantly ele- 
vated. At the same time there is considerable tenderness in the lower 
part of the abdomen, the uterus is larger and more doughy in consistency 
than it should be, and is more or less sensitive on pressure. The lochial 
discharge may decrease slightly in amount if the temperature be high, 
but in the majority of cases it is increased in amount, and we have an 
abundant, bloody, more or less purulent secretion, which in the purely 
septic forms of endometritis is devoid of odor. The absence of odor 
from the uterine discharges in these cases is of the greatest practical 
importance, for the average practitioner associates puerperal infection 
with profuse and foul-smelling lochia; while the fact is that in the most 
virulent cases, and especially those due to pure streptococcus infection, 
there is very little, if any, odor to be noticed. 

Another point of importance in endometritis is the lack of involution 
of the uterus. This must be looked upon as a factor which plays an 
important part in the further spread of the disease; for, as we have 
already stated, the micro-organisms make their way from the endo- 
metrium through the muscular walls of the uterus by means of the lym- 
phatics, and w r hen the uterus is markedly relaxed it is apparent that the 
lymph-channels must be more patent and offer far less resistance to their 
outward passage than when the uterus is firmly and normally contracted. 

The further history of septic endometritis varies according as the pro- 
cess remains limited to the cavity of the uterus or extends beyond it. 
If it remains limited to the uterus, the temperature gradually falls, the 
secretion becomes less and less, and the patient is slowly restored to 
health. In the majority of cases, however, the uterine mucosa is not 
restored to its normal condition at once, but for a long time remains in a 
condition of subacute or chronic inflammation. If, on the other hand, 
the process extends beyond the uterus, the symptoms will vary according 
to the organs involved, and the clinical picture will be complicated by 
the appearance of symptoms characteristic of a parametritis, peritonitis, 
or pyaemia . 

The symptoms of putrid endometritis vary considerably from those of 
the septic form. In this we likewise have the initial chill and the high 
temperature, but the patient's condition does not usually appear so seri- 
ous. But the main difference between the two varieties of the affection 
is to be noted in the character of the uterine discharge, which in the 
putrid cases is abundant, very foul-smelling, and frequently contains 
large numbers of gas bubbles, which give it a frothy appearance. These 
cases usually terminate in recovery, and only in rare instances give rise 
to a fatal termination. 

Between these two well-marked classes of cases, however, there exist 



PATHOLOGY OF THE PUEBPEBIUM. 

all forms of gradation, f'<>r we frequently have to deal \\ ith a mixed infec- 
tion due to pyogenic as well as putrefactive organisms. 

A- we have already indicated when considering the pathological anat- 
omy of the puerperal nicer, it is not infrequent to find the chill and rise 
of temperature associated with an ulcer about the vulva or somewhere in 
the vagina. In the vast majority of cases, however, the puerperal ulcer 
rarely occurs alone, but is usually associated with an endometritis. I ne 
same may he said of puerperal vaginitis, for it is extremely rare for the 
in lection to be limited to the vagina alone. 

If the process has extended from the uterine cavity or from ulcers 
about the cervix to the parametrium, we meet with symptoms which are 
more or less characteristic of the affection. In many cases the initial 
rise of temperature gradually disappears, and we are congratulating our- 
selves that our patient has escaped so easily, when suddenly there i< a 
chill and the temperature rises again, and then pursues a more or less 
irregular course, usually marked by exacerbations in the evening. 

This may continue for a longer or shorter period without any local 
manifestation, hut sooner or later, on abdominal palpation, we feel a mass 
arising on one or both sides of the uterus, which is due to abscess forma- 
tion within the folds of the broad ligament. This abscess may be limited 
to the broad ligament itself, or may follow the lymphatics of the pelvic 
connective tissue along the anterior side of the pelvis up to the neigh- 
borhood of Poupart's ligament, or extend backward toward the retro- 
peritoneal region. The temperature will continue until the abscess has 
ruptured spontaneously or been opened with the knife, except in a few 
cases in which it undergoes gradual resorption, leaving a mass of cica- 
tricial tissue to mark its former situation. Unless the parametritic 
abscess ruptures into the peritoneal cavity, the patients usually recover; 
and if not operated upon, the abscess bursts into the rectum or bladder, 
and occasionallv through the abdominal wall in the inguinal region. 

In a certain number of cases the infection extends from the uterine 
cavity to the Fallopian tubes, and there gives rise to a salpingitis with 
its accompanying symptoms, and many a case of pyosalpinx, which is 
operated upon later, is the result of the extension of the process from the 
endometrium. 

Unfortunately, in a considerable number of cases, the infection does 
not remain limited to the uterus or the parametrium, but the micro- 
organisms make their way through the lymphatics of the muscular wall 
of the uterus to the peritoneum, where they give rise to a peritonitis. 
In rare instances the peritonitis is the result of extension of the process 
from the tubes, and in still other cases to the rupture of a parametritic 
abscess or pyosalpinx. 

In a small number of cases the peritoneal involvement is limited to 
the portion lining the pelvic cavity, when we have to deal with a 
pelvic peritonitis. If the process remains limited to the peritoneal 
cavity, the chances are that it will eventuate in recovery; but if a greater 
portion of the peritoneum be involved, the death of the patient is to be 
predicted. The characteristic symptoais of peritonitis may make their 
appearance at almost any time during the puerperium, but rarely before 
the third or fourth day, and rarely later than the end of the first week, 
unless it be due to the rupture of an abscess. 



PUERPERAL INFECTION. 589 

When the patient is infected with virulent streptococci, the endo- 
metritic involvement is usually very slight, and the first sign of infec- 
tion appears from the side of the peritoneum. Here we notice the chill 
and the high temperature, which remains constantly elevated; the pulse 
becomes rapid and in the latter part of the affection very weak and 
thready. The patient complains of intense pain, which is at first limited 
to the lower portion of the abdomen, but gradually extends over the 
entire abdomen. At the same time there is marked tympanites, and the 
abdominal walls are rendered firm and tense by the distended intestines. 
If a fatal issue ensues, death usually occurs within the first ten days of 
the puerperium, the patient gradually sinking and dying in a conscious 
condition. 

In the cases of pyaemia, on the other hand, where the organisms have 
made their way into the venous channels, the clinical picture presented 
is a very different one. Here the initial chill does not occur so soon and 
the temperature does not remain constantly elevated, but instead we have 
a typical hectic fever, with the alternating chill, high temperature, and 
remission. The symptoms of pyaemia vary very considerably, according 
as it is the result of the dislodgement of a single thrombus, or of the 
constant supply of the blood with small portions of infected thrombi. 
In the first instance we have a metastasis produced at some one point, 
whose symptoms will vary according to the organ involved. On the 
other hand, if the thrombi are being constantly dislodged we may have 
symptoms referable to various organs. 

One of the most constant symptoms of pyaemia is an infectious broncho- 
pneumonia, which frequently leads to a fatal termination. In other cases 
we notice swellings at the various joints which frequently eventuate in 
suppuration and lead to their total destruction. The course of pyaemia 
varies very materially according to the organs involved and the power 
of resistance of the patient, and is nothing like so uniformly fatal as the 
peritonitic form of infection. 

In a certain number of cases, the infection is so virulent that the organ- 
isms do not have a chance to become localized in any one organ, and we 
find them and their toxins in very large numbers in the blood, with very 
slight involvement of the uterus. This we designate as septicaemia, 
which is the most rapidly fatal form of infection; the patients in many 
instances dying on the second or third day of the puerperium in a con- 
dition of shock, and without the development of local symptoms. 

In a small number of cases infected thrombi, instead of going to the 
lungs or other organs, make their way into the femoral vein and there 
give rise to phlegmasia alba dolens. This usually does not make its 
appearance until some time in the second week of the puerperium, or later, 
when the patient begins to complain of more or less pain in the line of 
the femoral vessels in one limb and soon notices a swelling of the part, 
which extends from above downward. This affection is extremely pain- 
ful and usually lasts for a considerable time, but does not lead to death 
unless some complication occurs. In many cases of phlegmasia the onset 
of the disease is associated with pain about the chest. This symptom 
has been dwelt upon by Pinard and AV allien 1 in their recent work on the 

1 Pinard and Wallich. Traitement de l'infection puerperale. Paris, 1896. 



590 PATHOLOGY OF THE PUERPERIUM. 

treatment of puerperal infection, and attributed by them to the involve- 
ment of the pleura 1 by small thrombi, which gives rise to isolated areas 
of pleurisy. 

In a certain number of cases, infection may occur before the birth of 
the child. These we designate as " infection intra-partum." This 
usually occurs in slow labors in which the membranes are ruptured at 
an early period. In these cases the temperature may be markedly ele- 
vated and the patient present a markedly septic appearance during the 
progress of labor. When the temperature during labor rises above 
L00.5 F. we should always think of this complication, which should 
indicate its speedy termination. 

Diagnosis. The diagnosis of puerperal fever does not usually offer any 
difficulty to the physician in charge, as the clinical history is very signifi- 
cant. 

If, in a patient who has been previously well, we have a chill and rise 
of temperature on the third or fourth day of the puerperium, we may be 
practically sure that we have to deal with an infection, unless we can 
account for the symptoms by some other perfectly apparent cause. In 
many cases the initial chill does not occur, and we simply have the rise 
of temperature, and we may say in general terms that a rise of tempera- 
ture to 100.4° F. or higher, which persists for more than twenty-four 
hours, is, a priori, evidence of infection. 

In the old times it was believed that the onset of the lacteal secretion 
was accompanied by fever, and the older observers always looked for the 
rise of temperature on the third or fourth day, when the secretion of 
milk first appears, and designated it as " milk fever." At the present 
time, however, we no longer believe in its occurrence, and we know that 
the normal puerperium should be absolutely free from fever. It is cus- 
tomary, in speaking of the puerperium, to consider a rise of temperature 
to 100.4° F., or 38° C, as within the bounds of normal. But when this 
point is reached we are obliged to look for some cause for the tempera- 
ture, which in the vast majority of cases will be found in an infection 
from without. 

After the infection has become well established, either as endome- 
tritis, peritonitis, or one of the other forms, the diagnosis is usually easy. 
In the cases of puerperal endometritis in which there is no involvement 
of the perimetrium or parametrium, usually very little pain is observed, 
and it becomes a difficult matter to decide positively whether the tempera- 
ture is due to a uterine infection or to some other cause. 

lu a certain number of iustances, we may observe a rise of temperature 
on the third or fourth day of the puerperium, which may be due to 
mental causes, such as emotional excitement, fright, or grief. In these 
instances the temperature rises suddenly, and may reach a considerable 
height, and promptly falls within a few hours to the normal. These 
cases at the onset may simulate an infection, and it is only by the rapid 
subsidence of the symptoms that we are able to make a diagnosis. 

In a certain number of cases also, we may have a rise of temperature 
caused by auto-infection from the intestinal tract. Special attention 
has been devoted to this subject by Budin 1 and Gal tier, 2 who state that 



Galtier. De l'infection primitive du liquide amniotique apres la rupture prematuree des mem- 
nes de l'oeuf humain. These de Paris, 1895. 



PUERPERAL INFECTION. 591 

in some instances the auto-infection arising from intestinal affections may 
closely simulate puerperal infection. The diagnosis is readily made, 
however, by the administration of a strong laxative, for after a copious 
movement of the bowels the temperature rapidly falls and remains 
at the normal line. 

We not infrequently notice a rise of temperature occurring in the early 
part of the puerperium, which is due to inflammatory troubles about the 
breasts, but the subsequent history of the case readily clears up the 
question of diagnosis. 

These are the most usual causes of rises of temperature daring the 
puerperium which are not connected with puerperal infection. But 
many intercurrent affections may give rise to a chill and high tempera- 
ture, which for a short time may cause us to fear puerperal infection; 
but the subsequent history of the case soon teaches us that our fears are 
groundless. This is frequently the case in angina and the acute pulmo- 
nary affections, which may occur at any time during the puerperium. 
There are two diseases, however, which are frequently confounded with 
puerperal fever, and which are also made the scapegoat to shield the 
practitioner who has neglected aseptic precautions in the conduct of his 
case. These are malarial fever and typhoid fever. There is no doubt 
that either of these affections may occur during the puerperal period, 
but in the vast majority of cases the diagnosis of malarial fever and 
typhoid fever during the puerperium is made to shield the practitioner 
from the consequences of his own neglect. 

Occasionally, in prolonged suppurative processes about the pelvis, we 
have symptoms which may readily be confounded with one or the other 
of these affections, but in the present state of our knowledge there is no 
reason why we should long remain in doubt as to the cause and origin of 
the fever in a given case. 

If we have to deal with malaria, we should be able to demonstrate in 
the blood the presence of the malarial plasmodium, and, unless the blood 
has been carefully examined and the malarial organism demonstrated, 
we do not consider that any one is justified in regarding as malarial any 
puerperal patient who has an elevated temperature and an occasional chill. 

The writer in his own practice goes still further than this, and would 
not attribute a rise of temperature in the puerperium to malaria to the 
exclusion of puerperal infection, unless he had conclusively demonstrated 
the presence of the malarial organisms in the blood of the patient, and 
likewise demonstrated by cultural methods that the uterine cavity was 
free from all pathogenic organisms; for it is possible that in a certain 
number of cases we may have puerperal infection associated with mala- 
rial poisoning, and under such circumstances, without the bacteriological 
examination of the uterine lochia, we would be satisfied of the malarial 
origin of the symptoms upon finding the plasmodium in the blood; whereas 
it in reality only explains a portion of the symptoms. Judged by these 
criteria, malaria complicating the puerperium will occur far less fre- 
quently than is at present said to be the case; but there is absolutely no 
doubt that it occasionally occurs, as the writer recently demonstrated in 
his own work. In this case we were able to demonstrate the presence 
of quartan malarial organisms in the blood of the patient, and at the 
same time to demonstrate the absolute sterility of the uterine lochia. 



592 PATHOLOGY OF THE PUERPERIUM. 

The diagnosis of typhoid fever is very frequently made in the post- 
puerperal infections, and is based by the average observer upon the fong- 
continued fever and the general prostration of the patient The writer, 

while be believes that in rare in-tanct s typhoid fever may complicate the 

puerperium, as well as any other condition, is confident that only a .-mall 

proportion of the cases which are thus designated are really typhoid in 
origin, but that most of them depend upon the uterine infection. And 
in the present state of our knowledge, especially since WidaPe discovery 

of the agglutinative action of the blood Berum of typhoid patients upon 
cultures of typhoid bacilli, we are not justified in making a diagnosis of 

typhoid 'fever unless this specific action can be demonstrated. And we 
might say that every rise of temperature during the puerperium should 
be regarded as due to infection unless we can clearly demonstrate some 
other affection to be its cause. 

Therefore, in making a diagnosis of any affection complicating the 
puerperium, an accurate and complete physical examination of the patient 
is necessary, and it should be combined with all the aids which the recent 
advances in microscopy and bacteriology have placed at our command. 

As we have already stated, the most common form of puerperal infec- 
tion is an endometritis, which is either of the putrid or septic variety, 
and it is a matter of the greatest possible importance to decide with which 
form of endometritis we have to deal. In many cases the clinical symp- 
toms will indicate with tolerable accuracy whether we have to deal with 
a sapraemic or septic condition; but the only method by which we can 
arrive at a positive conclusion is by taking cultures from the interior of 
the uterus, when we will obtain putrefactive organisms in the sapra?mic 
form, and the pyogenic organisms, and especially the streptococcus, in 
the septic forms. 

Cultures may be taken from the interior of the uterus with compara- 
tively little difficulty by means of the lochial tube, which was first intro- 
duced by Doederleiu, 1 and which consists of a glass tube 20 to 25 cm. in 
length and 3 to 4 mm. in diameter, with a slight bend at one end so as to 
conform to the anteflexed condition of the uterus. It is sterilized either 
by dry heat or steam, and is then ready for introduction. In practice 
the most convenient method for sterilizing the tube and enabling us 
to carry it with us in a sterile condition is to place it in a long test-tube 
of thick glass, which contains at its lower extremity a small amount of 
cotton, and whose upper end is filled by a cotton plug, just as one closes 
the ordinary culture tubes which are employed in bacteriology. The 
lochial tube is then sterilized within the test-tube, and may thus be carried 
from place to place without fear of contamination. 

When we wish to make cultures from the uterus our hands and the 
external genitalia should be thoroughly disinfected, the patient placed 
in Sims' s position, and a sterilized Sims' s or Simon's speculum introduced 
so as to retract the posterior vaginal wall, then the cervix caught with 
a sterile volsellum forceps and brought down to the vulva. The vaginal 
portion of the cervix is then carefully cleansed with a bit of sterilized 
cotton, and the sterile lochial tube is removed from its tube and introduced 
into the uterus as high up as it will go, care being taken to avoid touch - 

1 Doederlein. Untersuchung iiber das Vorkomen von Spaltpilzen in den Lochien des Uterus und 
der Vagina gesunder und kranker Wochnerrinnen. Arch. f. Gyn., 1887, xxxi. 412. 



PUERPERAL INFECTION. 



593 



ing the external genitals in the operation. To the end of the tube which 
protrudes from the vulva, a syringe, which draws well, is attached 
by means of a rubber tube. Suction is made, whereby a certain amount 
of the uterine contents is drawn up into the tube. The tube is then 
removed and its ends sealed with sealing wax, when it can be carried to the 
laboratory without fear of contamination. On reaching the laboratory 



Fig. 355. 



Fig. 356. 



Fig. 357. 




urn 



it is broken in its middle portion and cultures taken from its contents, 
which we know represent the uncontaminated lochia from the upper part 
of the uterus. Fig. 355 shows the lochial tube within its test-tube, 
Fig. 356 the tube ready for use, with the syringe attached, and Fig. 357 
the tube sealed and ready for transportation to the laboratory. 

While this method appears somewhat complicated, it can readily be 

38 



594 PATHOLOGY OF THE PUERPERIUM. 

carried <>ut by any one who is conversant with the ordinary rules of sur- 
gical technique, and the tube then sent to the laboratory for examination. 
By this meanfl we are able within twenty-four hours to know with cer- 
tainty whether our infection is due to sapneinic or pyogenic organisms, 

•and w betber we have to deal with a comparatively harmless or a danger- 
ous affection. 

Marmorek 1 in his article on the anti-streptococcus serum strongly 
urges the bacteriological examination of every case of puerperal infection. 
The writer makes it a part of the routine examination in every case 
presenting a rise of temperature above 101°, and the satisfaction of 
knowing exactly with what form of infection he may have to deal amply 
repays him for the trouble taken, and at the same time gives him impor- 
tant indications as to treatment. 

Pinard, 2 in his recent work on puerperal infection, scoffs at the idea of 
bacteriological examinations in puerperal fever, and states that "they 
are beyond the scope of any except trained bacteriologists." But the 
writer's personal experience is opposed to his, and he believes that this 
method of diagnosis can be adopted by any one who knows how to dis- 
infect his hands and who lives within reach of a competent bacteriologist. 

Just after removing the lochia by the lochial tube it is the writer's 
practice to introduce his sterile finger into the uterus and feel its interior. 
This procedure gives us very important information, and enables us in 
many cases to predict in advance the result of the bacteriological exami- 
nation, and gives us important information as to the line of treatment to 
be pursued. 

In the vast majority of cases in which we have to deal with putrid 
endometritis and those forms due to the colon bacillus, we usually find 
the surface of the uterus rough and covered by shreds of broken-down 
tissue; while in the septic forms of endometritis, and especially those 
due to virulent streptococci, the interior of the uterus is frequently per- 
fectly smooth to the examining-finger. And we may say, as a general 
rule, when the uterine cavity is rough and contains shreds of broken- 
down material, that we have to deal with infection by putrefactive organ- 
isms or pyogenic organisms of a moderate degree of virulency; whereas, 
when it is perfectly smooth to the examining-finger, we may be almost 
sure that we have to deal with a virulent streptococcus or staphylococcus 
infection. 

The mere inspection of the lochial discharge is also of considerable 
value, for in the cases of putrid endometritis it is frothy and frequently 
very offensive in odor, while in the cases of pure streptococcus infection 
it is very little changed from the normal. This distinction is of impor- 
tance, because the first question which the practitioner usually asks 
of the nurse, in the presence of fever in the puerperium, is whether the 
lochia are foul-smelling or not, and, if he receive a negative answer, he 
feels fairly sure that the fever is of other than uterine origin; whereas 
almost the reverse is true, and, as a rule, the fouler the odor, the less 
is the danger to which the patient is exposed, and vice versa. 

When the process has extended beyond the uterus, the diagnosis is 

1 Marmorek. Le streptocoque et le serum antistreptococcique. Annales de l'lnst. Pasteur, 1895, 
ix. 593-620. 

2 Pinard and Wallich. Traitement de l'infection pu£rp6rale. Paris, 1896. 



PUERPERAL INFECTION. 595 

much more readily made, and with the exception of malaria no one can 
mistake the symptoms produced by a peritonitis or by a pyaemia. In 
the cases of parametritis and suppurative affections of the tubes and 
ovaries, the vaginal examination will demonstrate the presence of a 
tumor mass on one or the other side of the uterus, if the tumor has not 
already made itself evident to abdominal palpation. 

Treatment. Preventive. In considering the treatment of puerperal 
fever, prophylaxis should occupy the most important place. As has 
been repeatedly pointed out in the course of this article, puerperal infec- 
tion is wound-infection, and is due to the introduction of pathogenic 
micro-organisms by the hands or instruments of the doctor or nurse, 
and, therefore, the most scrupulous asepsis during the conduct of labor 
is the means upon which we have to rely to limit the occurrence of 
puerperal infection. Every physician who conducts a labor case should 
strongly feel his personal responsibility in this connection, and he does 
not do his full duty to his patient unless he regards the rules of asepsis 
as carefully as when performing a capital surgical operation. 

The first point, therefore, in the prophylaxis of puerperal infection is 
the consideration of the preparation of the patient and the disinfection 
of the hands and instruments of the accoucheur. 

At the onset of labor the patient should receive a full bath and a rectal 
enema. And before each and every vaginal examination the external 
genitals, and especially the region about the perineum and anus, should 
be most scrupulously washed with soap and hot water and then rinsed in 
1 : 1000 bichloride solution, after which a pledget of absorbent cotton 
or a towel soaked in the same solution should be placed over the vulva 
and, allowed to remain there until the physician is ready to make the 
examination, remaining in place for at least three minutes. If an opera- 
tive procedure is to be undertaken the buttocks of the patient should 
be placed upon sterilized towels or sheets, and the legs of the patient 
enveloped in the same manner, so as to avoid the possibility of contami- 
nating the hands by organisms adhering to the bedclothes or clothing of 
the patient. If sterilized towels are not at hand, freshly washed towels 
taken directly from the drawer should be used. 

The best method of hand-disinfection has for a long time been a matter 
of dispute, and observers have not yet agreed as to the most practicable 
means of rendering the hands sterile. It may, however, be definitely 
stated that any method which will render the hands sterile, or even 
comparatively so, will require at least ten minutes. 

The rapid method of hand-disinfection which was introduced by Fiir- 
bringer, 1 by which, it was stated, the hands could be rendered abso- 
lutely sterile in three minutes, has been shown by later experiments to 
be absolutely inefficient. And the rapid method of hand-disinfection by 
means of alcohol, which was introduced by Reinicke 2 in ZweifeFs clinic 
in Leipsic, has been shown, by the careful work of Menge and Kronig, 
to be based upon a fallacy, as they showed that the alcohol did not pos- 
sess a markedly germicidal action, but simply produced conditions in the 

1 Fiirbringer. Untersuchungen und Vorschriften tiber die Desinfection der Hande des Arztes nebst 
Bemerkungen tiber den bakteriologischen Cbarakter des Nagelscbmutzes. Wiesbaden, 1888. 

2 Reinicke. Bakteriologische Untersuchungen tiber die Desinfection der Hande. Arch. f. Gyn., 
1895, xbx. 515-558. 



596 PATHOLOGY OF THE PUEMPEBIUM. 

skin which for the time being rendered it difficult to remove the organ- 
isms from the surface <>f the hands. 

At the present time the l>est method of hand-disinfeet ion with which 
the writei- is familiar is the one introduced by Dr. Elalsted at the Johns 
Hopkins Hospital some year- ago, and described by Dr. Kelly. 1 

Bacteriological examination shows that it is capable of yielding better 

results than any other method, though in a certain number of eases it 
fails to produce absolutely sterile hands. The following directions are 
copied from the regulations for hand-disinfection which are posted over 
every wash-basin in the lying-in ward of Johns Hopkins Hospital : 

1. Cat the finger-nails with clippers or scissors to 1 mm. in length. 

2. Scrub the hands and forearms up to the elbows vigorously with 
nail-brush, green soap, and hot water for at least five minutes by the 
clock, or until they are macroscopically clean, paying especial attention 
to the nails and palmar surface of fingers. The water must be changed 
at least once. After changing it, remove dirt from beneath the nails with 
nail cleaner or penknife, and then renew the washing. 

3. Kinse the hands in fresh water, soak then in a hot saturated solu- 
tion of potassium permanganate until they take on a deep mahogany- 
brown color. 

4. Dissolve this off in a hot saturated solution of oxalic acid. 

5. Then soak the hands and forearms in a 1 : 1000 bichloride solution 
for three minutes by the clock. 

6. Touch nothing until ready to examine the patient, going directly 
from the bichloride solution to her. 

The only objections which can be made to this method of hand-disin- 
fection are the length of time which it requires and the roughness of the 
hands which is sometimes produced by it. The first objection cannot be 
overcome, as the writer does not believe any one can thoroughly disinfect 
his hands in less than ten minutes, whether one uses permanganate and 
oxalic acid or not. The second objection can be obviated to a consid- 
erable extent by anointing the hands with a glycerin ointment after the 
examination is made. 

If this method of hand-disinfection and the preparation of the patient 
are thoroughly carried out, the danger of examination is reduced to a 
minimum. 

In view of what has already been stated concerning the bacterial 
contents of the vagina, and the result of experiments by Leopold 2 and 
others with the prophylactic vaginal douche, and also as the result 
of his ow-n personal experience, the writer strongly advises that the 
prophylactic douche be not employed as a matter of routine, but that it 
be resorted to only when the vaginal secretion presents marked evidences 
of abnormality. 

As long as vaginal examinations are made, no matter how carefully 
we have attempted to disinfect our hands, infection will occasionally 
occur. This is due partly to the fact that hand-disinfection under some 
circumstances is much more difficult than is generally believed and partly 

• Kelly. Hand Disinfection. Amer. Journ. Obst., 1891. xxiv. No. 12. 

2 Leopold. Vergleiebende Untersuchungen iiber die Entbehrlichkeit der Scheidenausspulungen 
bei ganz normalen Geburten und iiber die sogenannte Selbstinfektion. Arch. f. Gyn., 1894, xlvii. 
580-635. 



PUERPERAL INFECTION. 597 

to the unwitting contamination of onr hands before making the examina- 
tion. Therefore vaginal examinations should be limited in number as 
much as possible, and in normal cases one or two vaginal examinations 
are all that is necessary, if the accoucheur is acquainted with the methods 
of external examination. 

In a large number of cases labor can be conducted with absolute 
safety and ease by means of external manipulations alone, without a 
single vaginal examination. And the writer believes that the only value 
of the vaginal examination during labor is to ascertain the degree of 
dilatation of the cervix and to estimate the probable duration of labor. 
All other points for which we seek information by the vaginal examina- 
tion are made out far more clearly by the external examination, and were 
we to be debarred from one or other form of examination, we would 
prefer to give up the vaginal. 

The recent articles of Leopold and Sporling, 1 and Leopold and Orb, 2 
show the extreme accuracy of external examination, and they state that 
it is possible from their own experience to deliver at least 90 per cent, of 
all cases by means of the external examination. And their observations 
show that the number of errors in diagnosis become more and more 
infrequent as the obstetrician becomes better trained in this mode of 
examination; for example, in the first 1000 cases which they delivered 
by this means there were 6.5 per cent, of errors of diagnosis, whereas 
in the last 1000 cases the errors were reduced to 1.77 per cent. 

This clearly shows us what can be accomplished by external examina- 
tion alone, and its importance cannot be too strongly urged upon the 
accoucheur. It is perfectly harmless and can be employed as often as 
desired, and, unlike digital examination, does not require the laborious 
hand-disinfection. This method of examination should always be em- 
ployed to the exclusion of the vaginal examination whenever the vaginal 
secretion presents an abnormal appearance which leads us to suppose that 
it contains pathogenic micro-organisms. But still more important is its 
employment in cases when the accoucheur is not sure of the cleanliness 
of his own hands, as after intra-uterine manipulations with puerperal 
sepsis and the performance of autopsies upon septic cases, etc. Under 
such circumstances the vaginal examination should be resorted to only in 
case some marked complication arise during the course of labor. 

A few years ago Kronig 3 suggested that the vaginal examination could 
be replaced to a great extent by rectal examination, which would give 
all the information required, even to the degree of dilatation of the cervix. 
This method, however, cannot be indorsed, even though it is perfectly 
feasible, for the reason that the finger once introduced into the rectum 
cannot readily be disinfected, and if the subsequent course of labor should 
render the introduction of the hand into the vagina necessary we should 
expose our patient to a marked danger of infection, instead of obviating 
it, as we hoped by this mode of examination. 

All that has been said concerning the necessity of cleanliness and asep- 

1 Leopold and Sporling. Die Leitung der regelmassigen Geburten nur durch ausseren Untersuch- 
ungen. Arch, f Gyn., xlv. 339-371. 

2 Leopold and Orb. Die Leitung ganz normaler Geburten nur durch aussere Untersucbuug. Arcb. 
f. Gyn., 1895, xlviii. 304-323. 

3 Krbnig. Der Ersatz der inneren Untersucbung Kreissender durcb die Untersuchung per Rectum. 
Cent. f. Gyn., 1894, 235. 



\MM 



598 PATHOLOGY OF THE PUEBPEBIUM. 

sia on the part of the physician applies equally well to the nurse, and she 
should be strictly forbidden to make vaginal examinations or give douched 

except at the direct request of the physician in charge; otherwise, we 
have no mean- of knowing, in case infection ensues, whether it is the 

result of our own caielessne.— or that of the QUrse. 

During the second stage of labor it is well to have the vulva covered 

by an aseptic pad. This is done not so much for fear of infection from 

the aii- as to prevent the possibility of the patient contaminating herself 

with her own hands. 

The third stage of labor likewise offers many facilities for infection, 
and too much stress cannot be laid upon its proper conduct; and, 
generally speaking, the generative tract, after the birth of the child, 
should be regarded as a noli me tangere, except in eases of urgent 
necessity. 

Kxcepting severe hemorrhage and cases of adherent placenta, there is 
absolutely no indication for introducing the hand into the parturient 
tract. And I believe that the frequency of adherent placenta is very 
grossly over-estimated, and in many cases its occurrence is dne to the 
injudicious employment of Crede's method, which in the vast majority of 
cases is not necessary. The writer's practice is to watch the fundus of 
the uterus by placing his hand gently upon it, but not kneading it. After 
the lapse of ten or fifteen minutes, as a rule, we notice that the fundus 
rises about 5 cm. toward the umbilicus; this means that the placenta 
has been detached from the uterine wall and has been expelled either 
into the lower uterine segment or into the vagina. Under these circum- 
stances it is ready for expression, the body of the uterus being simply 
used as a piston to force the detached placenta through the vagina. 

If after waiting half an hour the fundus uteri does not rise up, as 
described, we should then resort to the typical Crede method of expres- 
sion. Observance of these directions will show that adherent placenta 
is of very rare occurrence, indeed, and will not necessitate the introduc- 
tion of the hand in utero more than once in several hundred cases. 

The practice recommended by Grandin, 1 Palmer Dudley, 2 and others, 
who advocate routine vaginal examination at the conclusion of the third 
stage of labor, to detect cervical tears, which they believe should be 
repaired immediately, cannot be too strongly deprecated, and those 
who follow their advice will surely find that a much larger proportion 
of their patients present abnormal puerperia than if they reserved the 
vaginal examination at the conclusion of the third stage of labor for 
exceptional and urgent cases. 

Another point in the prophylaxis of puerperal infection is attention to 
perineal tears, and every tear which extends deeper than the mucosa 
should be sutured immediately after the conclusion of labor, unless it be 
contraindicated by the general condition of the patient or by a very 
cedematous condition of the parts. To save time, it is the writer's 
practice to introduce the sutures immediately after the birth of the child 
and while waiting for the expulsion of the placenta. Their ends are 

1 Grandin. Late Infection in the Puerperal State; being a plea for the routine manual examina- 
tion of the interior of the uterus after the completion of the third stage of labor. Trans. Amer. Gyn. 
Soc, 1895. xx. 462-468. 

2 Dudley. Immediate Repair of Lacerated Cervix. Trans. Amer. Gyn. Soc, 1895, xx. 343. 



PUERPERAL INFECTION. 599 

then grasped by artery-forceps and are tied as soon as the placenta has 
been expelled. This method, beside resulting in the saving of con- 
siderable time, is also beneficial in that it gives us something to do 
during the third stage of labor, and does not so often expose us to the 
temptation of premature expression of the placenta. 

After the third stage is ended the patient should be cleaned and 
dressed with an aseptic vulval pad, which is held in place by a 
T-bandage. 

During the puerperium the external generative organs should be fre- 
quently cleansed with a 1 : 2000 or 1 : 4000 bichloride solution applied 
by means of an irrigator or on small pieces of cotton. The writer 
strongly deprecates the routine use of douches during the puerperium, 
and considers that they should be given only under exceptional circum- 
stances, and when employed should be given by the doctor himself, unless 
he has a nurse who is thoroughly versed in aseptic technique and upon 
whom he feels he can confidently rely. In several cases the writer has 
seen infection in the later periods of the puerperium from the use of 
dirty syringes in the hands of a nurse. 

Curative. When we come to the consideration of the curative treat- 
ment of puerperal sepsis we have to deal with a question about which 
there is still a great deal of dispute, and what we shall say will probably 
stand in marked contrast to much of the current practice in this regard. 
If we find a puerperal ulcer about the perineum or lower portion of the 
vagina, the parts should be kept as clean as possible, and the ulcer occa- 
sionally touched with 50 per cent, carbolic acid or tincture of iodine. 
If the perineum has been repaired and its edges are suppurating, we 
should remove the stitches so as to obtain free drainage. 

Puerperal endometritis is the affection which we are called upon most 
frequently to treat, and it is here that the directions for treatment differ 
so greatly. 

As soon as our patient's temperature reaches 102° or 102.5°, unless 
we can certainly exclude uterine infection, we should investigate the 
uterus. The hand should be carefully sterilized and, as indicated when 
considering the diagnosis of the affection, a certain amount of the lochia 
should be removed from the uterus for bacteriological examination, 
after which the sterilized index finger should be introduced into the 
uterine cavity, and its interior carefully palpated. After this a care- 
ful bimanual examination should be made to ascertain the condition of 
the appendages and the broad ligaments. If we find the uterine cavity 
perfectly smooth and not covered with shreds of broken-down tissue, we 
may give a douche of several litres of boiled water or normal salt solu- 
tion, but should not think of curetting. On the other hand, if we find 
the interior of the uterus rough and jagged and containing more or less 
debris, it should then be thoroughly curetted and douched as above. The 
employment of the curette is not be recommended in all cases of puerperal 
endometritis, for the reason that in many instances, and these are usually 
the most severe cases, there is absolutely nothing which can be removed 
by it, and its employment can only do harm by breaking down the leuco- 
cytic wall which is intended to prevent the ingress of organisms into the 
deeper layers of the uterus. If, however, the uterus contains debris, the 
use of the curette is indicated. 



u 



600 PATHOLOGY OF THE PJJEBPEBIUM. 

The routine employment <>f the curette in all case- of puerperal infec- 
tion is advocated by mosl of the French and. American writers. Pinard 1 
and Doleris* arc particularly enthusiastic in this regard; while the Ger- 
mans, on the other hand, reserve its use for exceptional cases, Fritsch's 8 
views representing the usual German doctrines on this subject. En many 
cases the fingers will be a more efficient curette than the ordinary instru- 
ments, but this is a matter of personal taste. 

It will be noticed that nothing has been said about the employment of 
antiseptic douches in the treatment of puerperal endometritis. The writer 
regards the routine use of bichloride or carbolic injections in the treat- 
ment of these cases as productive of more harm than good. If we have 
to deal with septic endometritis produced by a virulent streptococcus, 
microscopical examination shows us that the organisms have penetrated 
far into the uterine wall by the time we get the initial chill and rise of 
temperature. Under these circumstances the employment of an anti- 
septic douche is not rational, as we know that it cannot reach the organ- 
isms in the uterine wall, which are giving rise to the symptoms and upon 
which the further spread of the disease is dependent. 

It has been experimentally shown by Burnm 4 that bichloride injections 
penetrate the tissues to only a very slight extent. He took the liver of 
an anmial dead of anthrax, soaked it for thirty minutes in a 1:1000 
bichloride solution, then placed it upon a freezing microtome and cut 
thick sections from it. After cutting off about j^ mm. he inoculated 
the next section into another animal, and found that it likewise died from 
anthrax, thus showing that the antiseptic action of the bichloride was 
exerted only upon the surface of the tissues. If this be the case in the 
laboratory, where the tissues are soaked in a bichloride solution for some 
time, what effect upon organisms lyiug in the muscle wall of the uterus 
can we expect from the passage of a few litres of bichloride solution 
through its cavity ? 

Bumm 5 likewise showed that the streptococci made their way from the 
uterus with great rapidity, and after infection in animals found that the 
streptococci could travel 2 cm. or more in the space of six hours. What 
has been said concerning bichloride applies equally well to the other dis- 
infectants. 

Now, when we come to consider their employment in cases of putrid 
endometritis, we shall find it even less rational than before. In the vast 
majority of cases of putrid endometritis, the simple cleaning out of the 
uterus with the finger or curette will lead to a rapid fall of temperature 
and the amelioration of symptoms. Our object in giving douches in 
most of these cases is simply to wash away debris which has been left 
behind by the curette or finger, and for this purpose sterile water is far 
better than any antiseptic fluid. The writer's results from this method 
of treatment are as good as those obtained by others who use the various 
antiseptic douches. In this opinion he is sustained by most of the men 

1 Pinard and Wallich. Traitement de l'infection puerp<§rale. Paris, 1896. 

2 Doleris. Curettage dans le sepsis puerperal. Nouv. Archives d'Obst. et de Gyn., Mai, Juin, 1886, 
Fev. Mars, 1887. 

3 Fritsch. Ueber Auskratzung des Uterus nach reifer Gebhrten. Zeit. f. Geb u. Gyn., 1S91, xxi. 456. 

4 Burnm. Ueber die verschiedenen Ferulenzgrade der puerperalen Infektion und die lokale Behand- 
lung bei Puerperalfieber. Cent. f. Gyn., 1893, 975. 

5 Bumm. Op. cit. 



PUERPERAL INFECTION. 601 

who have done bacteriological work in this connection, notably Bumm 1 
and Kronig. 2 

In addition to these somewhat theoretical objections to the employment 
of antiseptics in the treatment of these affections, there is the very prac- 
tical objection that injections of the various antiseptics are far from 
harmless. Any one who is conversant with the literature on the subject 
will recall the cases of sudden collapse following the use of carbolic-acid 
douches, while the employment of bichloride douches is sometimes the 
direct cause of death. Several years ago, the writer did an autopsy upon a 
woman supposed to be dead from puerperal sepsis, but he found all the 
anatomical lesions of bichloride poisoniug, and it was at least doubtful 
whether the sepsis or the treatment instituted for its relief had caused 
her death. 

In looking over the literature after this case, some 46 cases were found 
in which death had followed the employment of bichloride douches during 
the puerperium. In many instances death was clearly due to the employ- 
ment of overlarge quantities of bichloride; but in several cases a single 
injection of several litres of a 1 : 4000 bichloride solution resulted in the 
death of the patient from mercurial poisoning. 

When we take these facts into consideration, along with the theoretical 
objections to the employment of antiseptics under these circumstances, 
it would appear that the benefit to be expected from their employment 
is at least very problematical. 

To recapitulate, we would gay that in puerperal endometritis, after 
having removed lochia for cultures, the interior of the uterus should be 
explored by the sterile finger, and curetted or not according to its condi- 
tion. The uterus should then be douched w T ith several litres of boiled 
water or sterile salt solution, and packed with gauze. If the bacterio- 
logical examination show 7 s the presence of streptococci, we should at 
once desist from all further local treatment. If, on the other hand, we 
have to deal with a putrid endometritis, and the symptoms do not yield 
to the first injection, still other injections may be resorted to. If the 
infection has extended beyond the uterus, local treatment should not be 
persisted in, as it will then do far more harm than good. 

Bumm 3 pointed out in his article on puerperal endometritis that in 
many instances involution had taken place very incompletely, and he, 
therefore, recommended the employment of ergot to secure better con- 
traction, and thereby occlude to a greater or less degree the lymphatics in 
the uterine wall. My own experience confirms Bumm's 4 statements, and 
I would, therefore, earnestly recommend the employment of ergot in cases 
in which the uterus is larger than it should be at a given period of the 
puerperium. 

In the cases of gonorrhceal endometritis very little, if any, active treat- 
ment is required at the time, for in the vast majority of cases the slight 
rise of temperature which is noticed at the onset of the disease soon 
falls to normal, and our patients recover spontaneously or are left with 

i Bumm. Op. cit. 

2 Kronig. Aetiologie und Therapie der puerperal. Endometritis. Cent. f. Gyn., 1895, 422, 432. 
Discussion uber Endometritis. Verh. de deutschen Ges. f. Gyn., 1895, 498-502. 

3 Bumm. Histologische Untersuchungen liber die puerperal. Endometritis. Arch. f. Gvn., 1891, 
xl. 398. 

* Bumm. Op. cit. 



602 PATHOLOGY OF THE PUERPERIUM. 

a chronic endometritis} which can be treated much more advantageously 
at a later period. 

Schucking' Borne years ago recommended the continual irrigation of 

the uterine cavity with antiseptic solutions. His results, however, were 
not appreciably better than those obtained by others who used only the 
intermittent douche, and his methods of treatment never came into very 
widespread employment. With the French, however, the method found 

warm supporters, and is at the present time employed by Pinard* in 
almost every case of infection. 

If the method of treatment above outlined does not lead to an amelio- 
ration in the condition of the patient, all local treatment should be 
desisted from, and we should place our reliance upon general tonic treat- 
ment. Our most potent remedies in this regard are strychnine and 
alcohol, and it has been shown by Kunge 3 that women in this condition 
can bear much larger quantities of alcohol than when in health. The 
fever should not be treated with antipyretics, and if we feel that it should 
be abated, we may attempt it by the local application of cold, either in 
the form of sponges or cold baths. This method of treatment has been 
enthusiastically advocated by Mac6, 4 Runge/' and Desternes, 6 and accord- 
ing to them has given very satisfactory results. If the process has 
extended beyond the uterus, and we have to deal with a parametritis or 
a pelvic peritonitis, the application of heat to the lower portion of the 
abdomen, either in the form of poultices or other hot applications, is to 
be recommended. 

Of late a great deal has been written on the operative treatment of 
puerperal infection, nearly every prominent obstetrician and gynecologist 
in the country having made some contribution in this direction. Every 
one is agreed as to the advisability of opening parametritic abscesses as 
soon as fluctuation appears, rather than allowing them to rupture spon- 
taneously. In many cases of parametritis we may obtain on palpation 
a semi-fluctuation, which will lead us to suppose that we have to deal 
with pus, but upon opening the supposed abscess through the vagina or 
abdominal wall, as the case may be, we find that our tumor is a mass of 
inflammatory exudate without pus-formation, and only a small amount 
of serous fluid will escape when it is excised. The incision of these 
masses frequently leads to as good results as though we had evacuated a 
considerable quantity of pus, just as we obtain excellent results from free 
incisions in ordinary cases of cellulitis in other portions of the body. 

When we are able to demonstrate the presence of pus tubes or ovarian 
abscesses by bimanual palpation, their removal is urgently indicated, for 
as long as they remain our patient will continue in her septic condition. 

Whether we remove the pus tubes by laparotomy or puncture them 
through the vagina will depend upon their character. If the pus tube 
is freely movable laparotomy should be performed; while, on the other 
hand, if it be adherent and can be readily reached from the vagina, 

i Schucking. Quoted by Kehrer. Miiller's Handbuch der Geb., 1889, iii. 343. 

2 Pinard and Wallich. Traitement de l'infection puerpC>rale. Paris, 1896. 

3 Runge. Die Allgemeinbehandlung der Puerperalen Sepsis. Vierle Mittheilung, 1888, xxxiii. 
39-52. 

4 Mace. Traitement de la s6pticdmia puerperale par la refrigeration et en particulier par les bains 
froids. Gaz. des hop., 1894, 1367-1372. 

5 Runge. Op. cit. 

6 Desternes. Indications et role du bain froid dans le traitement de l'infection putiperale. These de 
Paris, 1895. 



PUERPERAL INFECTION. 603 

vaginal puncture with subsequent packing of the abscess cavity with 
gauze is to be preferred. 

The operations of which we have just spoken are usually not performed 
until the latter part of the puerperiurn, because it is not until then that 
definite tumor masses can be made out. 

The chief discussion concerning the operative treatment of puerperal 
infection has been as to the advisability of removing the infected uterus 
at an early period. Here the various observers take quite opposite views, 
the more radical surgeons advocating the early removal of the uterus, 
while the more conservative men do not regard it with great favor. 

It would appear to me that in the vast majority of cases hysterectomy 
in the early stages of puerperal infection is impracticable, for if we oper- 
ate at a period sufficiently early to prevent the extension of the process 
to other organs, we shall undoubtedly remove a large number of uteri 
unnecessarily; whereas, if we wait until a later period, when other 
organs have been involved, the operation will likewise be useless. There 
is, however, a restricted field for hysterectomy in puerperal infection, for 
in a certain number of cases we find that the process has not extended 
materially beyond the uterus, but has given rise to abscess formation 
within its walls. In such cases, if more conservative treatment fails, 
we should not hesitate to remove the entire uterus. Occasionally in rare 
cases of putrid endometritis nothing that we can do appears to check the 
disease, and in these cases also operation would appear justified. Such 
a case has been reported by Sippel, 1 in which, after the total failure of 
all other methods of treatment, hysterectomy resulted in the cure of the 
patient. 

In a recent article Lusk 2 states that there is probably a field for hys- 
terectomy in certain cases of uterine thrombosis when infected thrombi 
are carried off to various portions of the body, giving rise to a hectic 
condition. He declares that when this is observed, if the operation be 
done after, say, the second rise of temperature, it offers a very reasonable 
chance of success. Ko doubt in a small number of cases this may be 
true ; but in the majority of cases the thrombosis has extended far beyond 
the uterus when the pysemic symptoms make their appearance, and we 
would be obliged to operate through septic tissue. On the whole, the 
question of hysterectomy in this affection seems to depend altogether 
upon our ability to make a correct diagnosis and to foretell the course of 
the disease. This is a matter of great difficulty, and until more accu- 
rate means of diagnosis are at our disposal we do not believe that the 
operation will be very generally accepted. 

Three years ago our prospect of coping more successfully with puer- 
peral infection was brightened by Marmorek' s 3 announcement that he 
had discovered an antistreptoccocus serum. At the meeting of the Biolog- 
ical Society of Paris held February 23, 1895, Marmorek 4 stated that he 
was able, by growing streptococci upon a mixture of human blood-serum 
and repeatedly inoculating animals with it, to markedly increase the viru- 
lence of streptococci, so that he was able to obtain a culture so virulent 

1 Sippel. Supravaginal Amputation des septischen puerperalen Uterus. Cent. f. Gyn., 1894, 667-74. 

2 Lusk. Recent Bacteriological Investigations Concerning the Nature of Puerperal Fever. Amer. 
Journ. Obst., 1896. xxxiii. 337-347. 

3 Marmorek. Sur le streptocoque. Comptes-rend. de la Soc. de Biol., 1895, x serie, ii. 122. 
* Marmorek. Op. cit. 



604 PATHOLOGY OF THE PUERPEBIUM. 

thai the one-hundred-billionth of a cubic centimetre of it would kill 
a rabbit in thirty hours. By injecting this into immune animals lie was 
enabled to produce a preventive and curative serum. 

At the same meeting Charrin and Roger 1 stated that they likewise 
prepared a serum by the injection of sterile cultures of streptococci into 
lower animals, and reported two cases of puerperal infection which they 
had successful lv treated with it at the Paris Maternity. 

In July, 1895, Marmorek 2 published a long article in the Annates de 
r Insfifut Pasteur, in which he described in detail his method of preparing 
the serum, gave the results of the treatment of 413 cases of erysipelas 
with it, and, what interests us most, reported 16 eases of puerperal infec- 
tion which lie had treated with it. 

In all of these cases the uterine lochia were examined bacteriologically, 
and he found in seven cases he had to deal with a pure streptococcus 
infection, and that all seven recovered uuder the use of the serum; but 
that when the streptococcus was combined with other organisms the 
results were not so favorable, and of the nine cases of this character five 
resulted fatally. 

Since then this method of treatment has been employed by a number 
of observers in France and a few in England. The results, unfortu- 
nately, have not borne out Marmorek' s prediction. The writer has been 
able to collect from the literature 82 cases of puerperal infection which 
have been treated by antistreptococcus serum. The clinical history of the 
various cases appears to indicate that they represented the ordinary run 
of puerperal sepsis, some being more severe and others comparatively 
mild, and Bar and Tissier, 3 who reported their results in 26 cases, 
stated that their cases were taken one after another just as they occurred 
in the hospital. Of the 82 cases 52 recovered and 30 died, showing 
a mortality of 36.5 per cent. In 48 of the cases bacteriological exami- 
nation revealed the presence of the streptococcus either alone or in com- 
bination with other organisms. Of these 28 recovered and 20 died, 
giving a mortality of 42.5 per cent. Thirty-three cases were not exam- 
ined bacteriologically, and of these 23 recovered and 10 died, being a 
mortality of 30 per cent. 

This is a very discouraging showing, and it would appear that the 
results thus far obtained from the antistreptococcus serum are not better 
than those obtained by the other methods of treatment. 

The question, however, as to the value of the antistreptococcus serum 
cannot be decided by the few figures at our disposal. It appears that 
the theory upou which Marmorek 4 bases his work is essentially cor- 
rect, and that sooner or later we shall have a tolerably certain means of 
this character for combating the streptococcus infection. It is more 
than probable that a considerable part of the bad results there reported 

1 Charrin and Roger. Essai d 'application de la serum-therapie au traitementde la nevre puerperale. 
Comptes-rend. de la Soc. de Biologie, 1895, x serie, T. ii. 124-127. Application de la serum-therapie 
au traitement de quelques affections streptococciques. Comptes-rend. de la Soc. de Biol., 1895, x serie, 
T. ii. 224. 

2 Marmorek. Le streptocoque et le serum antistreptococcique. Annales de l'lnst. Pasteur, 1895, 
ix. 593-620. 

;i Bar aud Tissier. La Semaine med., 1896, 155. Seroth6rapie dans l'infection puerperale. L'Ob- 
stetnqne, 1896, 97-1 '28 and 204-217. 

4 Marmorek. Sur le streptocoque. Comptes-rend. de la Soc. de Biol., 1895. x serie, ii. Le serum 
antistreptococcique. Compt.-rend. de la Soc. de Biol., 1895, serie x. T. ii. 230-32. Le streptocoque 
et le serum antistreptococcique. Annales de l'lnst. Pasteur, 1895, ix. 593-620. 



PUERPERAL INFECTION. 605 

are due to the employment of an inefficient or worthless serum. Mar- 
morek 1 stated in his original article that the serums which he himself 
prepared varied very markedly in their protective power, some being 
fourteen times more potent than others, and it is apparent that if satis- 
factory results are to be obtained the most potent serums must be 
employed. 

In the 82 cases to which we referred a large number of serums, pro- 
duced in various places and by several means, were employed, and it is 
more than probable that a considerable part of them was absolutely 
worthless. We shall, therefore, not be able to make any definite state- 
ments as to the value of the antistreptococcus serum until we are able to 
obtain a serum of a constant and uniform protective power, which shall 
be clearly stated on the label of the bottle containing the serum, and 
even then the results obtained will not be absolutely reliable, for 1 know 
of no affection which varies more in the severity of its symptoms than 
the streptococcic forms of puerperal infection. 

Czerniewskr has reported a case, in which he found virulent strepto- 
cocci in the uterus, where the patient presented absolutely no rise of tem- 
perature, and the writer, in several instances, has seen cases in which on 
the third or fourth day of the puerperium there was a violent chill followed 
by a rise of temperature to 104° or 105°, the temperature remaining at 
that point for thirty-six to forty-eight hours, and then falling to normal 
without any treatment at all. In both these cases he was able to demon- 
strate the presence of a pure culture of virulent streptococci in the uterus. 
Had the antistreptococcus serum been employed in either of these cases 
there is no doubt that we should have attributed the rapid aud complete 
fall of temperature to its influence. Such cases show the extreme caution 
which must be employed before we can express a positive opinion as to 
the value of the serum, even when a perfectly reliable variety of it is at 
hand, and for the present at least we should not hold out any great amount 
of hope from its employment in private practice. 

That none of the methods advocated for the treatment of puerperal 
infection are wholly satisfactory is iudicated by the number of methods 
of treatment which have been from time to time advanced, and only a 
few of the more recent methods will be referred to. 

Thus, Fochier 3 advocates in pyasmic cases the production of what he 
calls " abscess de fixation " — that is, the production of abscesses on vari- 
ous portions of the body by the subcutaneous injection of turpentine; he 
states that he has observed in numerous cases of pyaemia that the condi- 
tion of the patient improved as soon as abscesses made their appearance 
on the surface, and in his method of treatment he attempts to simulate 
nature. This method has found few followers, and does not give promise 
of any great results. 

Kezmarezky 4 two years ago reported two cases of severe venous sepsis 
in which he had given intravenous injections of 1 to 5 mg. of sublimate. 

1 Marmorek. Le streptocoque et le s£rum antistreptococcique. Annales de l'lnst. Pasteur, 1S95, 
ix. 593-620. 

2 Czerniewski. Zur Frage von den puerperalen Erkrankungen. Eine bakteriologische Studie. 
Arch. f. Gvn., 1888, xxxiii. 73. 

3 Fochier. Traitement de l'infection puerperale par la provocation de phlegmons sous-cutanes. 
Ann. de Gvn., 1892. xxvii. 356-362. 

4 Kezmarezkv. Intravenose Sublimatinjection (Bacellij bei venoser Sepsis im Wochenbette. Cent. 
f. Gyn., 1894, 906. 



606 PATHOLOGY Or THE PUEBPEBIUM. 

lie stated thai in both cases a marked effect was apparent, and that both 
recovered. His work was enthusiastically taken up by Rissmann, 1 who 

likewise reported several cures from its employment. But it does not 
appear that this method of treatment will find many imitators. 

Another method of treatment lias been introduced during the past 
year by Hofbauer,* who reported seven cases of puerperal sepsis in which 

he produced an artificial leucocytosis by the employment of nuclein. In 

some of his cases the temperature fell by a lysis and in others by crisis, 
and he believed that the artificial leucocytosis played a marked part in 
their cure. Thus far no one has substantiated his results, but Hirst 1 
in a recent article states that he believes that more is to be expected 
from this line of treatment than from serum-therapy. 

In a recent number of the Presse Medica/e, Bosc 4 reports a case of 
puerperal sepsis in which he believed that he obtained very beneficial 
results from the subcutaneous injection of large quantities of salt solution. 
This method was likewise tried by Dr. Clark, of the Johns Hopkins 
Hospital, in a case of puerperal sepsis, in which he believed that the 
cure of the patient was due in great part to the injections of salt solution. 
It appears to the writer that we may find a useful adjuvant to treatment 
in this, though it, of course, should not be used to the exclusion of other 
means. In Dr. Clark's case the subjective relief afforded by the injec- 
tions was so great that the patient begged for more frequent injections. 

1 Rissmann. IntraveniSse Sublimatinjectionen bei Puerperalfieber. Frauenerzt, 1895, i. 240-244. 

2 Hof'baner. Zur Verwerthung einer kunstlicben Leukocytose bei der Behandlung septischen 
Puerperalprocesse. Cent. f. Gyn., 1896, 441-449. 

3 Hirst. Modern Methods in the Treatment of Puerperal Infection, and their Comparative Worth. 
Amer. Journ. Obst,, 1896, xxxiv. 180-184. 

4 Bosc. Injections de serum artificiel dans les maladies infectieuses et les intoxications. Presse 
med., 1896, Nr. 49, 287-290. 



CHAPTER XXVIII. 

MALFORMATIONS, INJURIES, AND DISEASES OF THE NEW-BORN 

CHILD. 

Malformations. 

Meningocele and Encephalocele. Owing to a congenital opening at some 
part of the skull, some portion of the cranial contents may protrude. The 
defect is most common in the occipital bone, in any portion of which the 
defect may be present, from the peripheral part to the centre. If it 
exists in the anterior portion of the bone, it may extend to the posterior 
fontanelle; if in the back part, it may connect with the foramen magnum. 
The size of the tumor depends, of course, upon the extent of the opening 
in the boue. Similar defects may also be present in the naso-frontal 
region, and less frequently in the basilar, temporal, and parietal segments 
of the skull. The openings may contain meninges alone, meninges with 
brain matter, or the latter with fluid in the interior; in the latter event 
the anomaly is termed hydrencephalocele. The tumors appear at or soon 
after birth. 

A meningocele is usually small, with little tendency to increase in 
size. It may be more or less pedunculated; it presents fluctuation, but 
no pulsation, and is usually reducible. 

In encephalocele there is distinct pulsation, and efforts at compression 
will be accompanied with evidences of marked cerebral irritation. The 
tumor, though not large, has a wide base, and is partly reducible. 

A hydrencephalocele is apt to be large, lobulated, with sometimes a 
distinct peduncle. Pulsation is usually absent in the tumor, which, 
however, is fluctuating and mostly translucent. Compression is not 
apt to be successful in reducing the tumor. Sometimes there is more 
brain-substance in the tumor than in the cranial cavity, and the infant 
is then microcephalic. 

Prognosis. The prognosis in hydrencephalocele is bad, as the tumor 
usually grows rapidly, and there may be rupture, with immediate death. 
In meningocele and encephalocele the prognosis is better, especially if the 
tumor be small. 

Treatment. Treatment in these cases is of little avail, although the 
withdrawal of fluid and even stimulating injections have been tried. 

Spina Bifida. Owing to congenital failure in the development of the 
vertebral arch, one or more of the laminae may be absent, with resulting 
protrusion of the spinal meninges. The lumbar region of the spinal 
column is the part usually affected. Occasionally, however, we have 
meningocele or encephalocele. (Fig. 320.) The tumor is round, fluct- 
uating, and by compression the cerebro-spinal fluid can be forced back 
into the spinal canal. Too severe pressure, however, may produce eclamp- 
sia or other grave cerebral symptoms. The base of the tumor depends 

(607) 



008 PATHOLOGY OF THE PUERPEBIUM. 

upon the size of the opening, being pedunculated if it is small, but more 
sessile if large. The tumor is usually covered with skin, which, how- 
ever, may be absent, exposing the dura mater. It* there is not much 
tissue covering the tumor, transudation may occur through the walls, or 
rupture of the sac may take place if growth is rapid. Some portion of 

the lower segment of the cord or the cau<la-e<|uiua is apt to he imprisoned 
in the sac. The extent of the involvement of nerve-tissue can he meas- 
ured by the paraplegia or other evidences of lesion in the spinal cord and 

nerve-. 

Gradual absorption of the fluid may occur, and the child may grow 
up with little inconvenience from the shrivelled tumor. This, of course, 
takes place only when the nerves are not involved. In most cases 
there is a gradual increase in the size of the tumor, with final ulceration 
or rupture, followed by convulsions or coma and death. The fatal ending 
may also come with a gradual emaciation accompanying paraplegia. 

Treatment. The treatment of small tumors consists in the applica- 
tion of a soft compress to avoid friction and to support the parts. When 
the tumor is growing, however, more energetic measures may be tried. 
The simplest procedure is to withdraw the fluid by aspiration, and 
follow this with gentle but constant pressure. The fluid must be slowly 
and cautiously removed, for fear of active nervous disturbance and even 
eclampsia. Injections with iodine of various strengths have been tried, 
but without much success. In some cases the tumor can be surgically 
removed by completely excising the sac. This may be successfully 
accomplished in the pedunculated variety where the opening in the 
lamina is small. It should never be attempted if there is evidence 
that the cord or cauda equina may be involved in the tumor. 

Cyanosis. New-born infants sometimes exhibit a persistent blueness 
due to malformation of the heart. This defect usually takes the form of 
deficiency in the inter-auricular and inter-ventricular septa. The great 
vessels may likewise be involved in the malformation, especially the pul- 
monary artery. Dr. J. L. Smith found in over half the cases he exam- 
ined by autopsy that the pulmonary artery was absent, rudimentary, 
impervious, or partially obstructed. He also found the following lesions : 
Right auriculo-ventricular orifice impervious or contracted; orifice of the 
pulmonary artery and the right auriculo-ventricular aperture impervious 
or contracted; right ventricle divided into two cavities by a supernumerary 
septum; one auricle and one ventricle; a single auriculo-ventricular open- 
ing, with inter-auricular and inter-ventricular septa incomplete; mitral 
orifice closed or contracted; aorta absent, rudimentary, impervious or par- 
tially obstructed: aortice orific and left auriculo-ventricular orifice imper- 
vious or contracted; aorta and pulmonary artery transposed, the vena 
cava entering the left auricle; pulmonary veins opening into the right 
auricle or into the vena cava or azygos veins; aorta impervious or con- 
tracted above its point of union with the ductus arteriosus; the pulmonary 
artery wholly or in part supplying blood to the descending aorta through 
the ductus arteriosus. 

It is obvious that with any of these grave central lesions, not only the 
peripheral circulation but the nutrition as well must suffer. The blood 
is deficient in oxygen and has an excess of carbon dioxide. The blue- 
ness is most pronounced in the prominent parts of the face, such as the 



INJURIES OF THE NEW-BORN CHILD. 609 

eyebrows, cheek-bones, nose, and lips. The hands and fingers are also 
prominently affected. The color varies from a light to a very deep purple, 
the discoloration being aggravated by crying or other disturbing influence. 

While the infants at birth may be well developed, there are soon 
evidences of failure of nutrition, aud they are very susceptible to inter- 
current diseases. The action of the heart is rapid and tumultuous, and 
the respiration is correspondingly disturbed. Various bruits are heard 
upon auscultation of the heart. The infants suffer from lack of suffi- 
cient animal heat, and because of this and pulmonary congestion they 
easily contract pneumonia. Most cases do not survive the first year, 
but if they live longer they present a stunted appearance, with peculiar 
bullous fingers and toes. 

All that can be done in the way of treatment is to strive to maintain 
the natural temperature and a fair nutrition. 

Malformation of the Rectum and Anus. Bodenhamer gives the following 
classification of the congenital defects of these- parts : (1) Congenital nar- 
rowing of the rectum or anus without complete occlusion; (2) complete 
occlusion of the anus by a membranous diaphragm or well-formed skin; 
(3) anus absent and rectum ending in a blind pouch at a point more or 
less distant from the perineum; (4) anus normal in appearance, but 
ending in a cul-de-sac, and the rectum ending in a blind pouch at a 
variable distance above this point; (5) anus absent and the rectum end- 
ing in a fistula opening at any point of the perineal or sacral region; (6) 
the anus absent, and the rectum ending in the vagina, the bladder, or 
the urethra; (7) the anus and rectum normal, but the ureter, vagina, or 
urethra opening into the rectal cavity; (8) the rectum totally absent. 

The time of the passage of the first stool and its size and character 
should always be investigated by the attending physician. Minor degrees 
of stenosis of the rectum or anus are not infrequent in the newly born. 
Although the thin feces of infancy may escape without difficulty, when 
the child grows older and the excreta become more solid, stenosis may 
occasion much inconvenience. 

Treatment. Congenital stenosis is best treated by gradual dilatation. 
A convenient bougie is the index-finger, well oiled, and daily inserted. 

When a thin band of membranous tissue closes the anus, a crucial inci- 
sion will open up the rectal pouch. For the graver forms of malformation, 
elaborate and careful operations are required, which, as they are fully 
treated in works on surgery, will not be considered here. 

Injuries During Birth. 

Excessive Moulding. In difficult labor, even though spontaneously 
completed, the child not infrequently suffers more or less serious injury 
during its passage through the birth-canal. As the head is the part of 
the foetus which normally offers the greatest resistance, it is the most 
frequent seat of such injuries. The soft and yielding character of the 
skull and the moulding to which it is frequently subjected may produce 
marked distortion. The diameter which falls in relation with the axis 
of the birth-canal is elongated at the expense of the engaging diameters. 
The head, however, usually resumes its normal shape within a few days 
after birth. 

39 



010 PATHOLOG ) OF. THE PUERPERITJM. 

Cephalhematoma is an effusion of* blood between the bone and the 
periosteum covering it. It usually appears within one to three days after 
birth. Its scat may be any portion of the cranial vault. Most com- 
monly it occurs in the parietal region, sometimes over the temporal or 
occipital hones. The overlying integument presents no discoloration. 
A bony ring is soon developed around the base. The effusion is, in most 
cases, limited by a suture. The effused blood, as a rule, undergoes absorp- 
tion within the first three months of life. In rare cases suppuration 
ensues, and even caries of the subjacent bone may occur. The fact that 
the tumor does not communicate with the brain cavity, which fact can 
usually be readily made out by palpation, serves to distinguish this affec- 
tion from encephalocele. 

TREATMENT. In most cases no treatment is called for. Should the 
tumor grow it may be strapped with adhesive plaster, the head first being 
shaved. Incision, while generally condemned, has been practised with 
success. It offers the advantage of immediate relief, and leaves no per- 
manent deformity. The effused blood can usually be removed through 
a small opening. A firm compress is worn for several days to prevent 
refilling. It is needless to say that the strictest asepsis must be observed. 
If suppuration occurs the usual surgical treatment of abscess must be 
carried out. 

Injuries to Bone and Muscles. The soft and partially developed con- 
dition of infantile bone renders it liable to injury if subjected to much 
mechanical violence during delivery. The cranial bones are especially 
liable to indentation and fracture when the forceps is employed, yet such 
accidents may occur in spontaneous labor. Fracture of the cranial bones 
is most frequently in the parietals. When the brain is not injured the 
fracture is not apt to result seriously. Rupture of intracranial blood- 
vessels may lead to fatal hemorrhage. Simple indentations apparently 
cause little if any damage to the brain structures. Gentle efforts at 
reduction may be attempted, and thus the normal shape be restored. 
Fracture of the inferior maxillary bone may result from traction with 
the fingers in unskilful delivery of the after-coming head in breech pre- 
sentations. Injuries may be inflicted upon the vertebrae or the spinal 
cord, with resulting paraplegia, and they are almost invariably fatal. 
Fracture of the humerus not uncommonly occurs in forcible delivery of 
the arm in breech births, or separation of the epiphysis from the shaft of 
the bone may take place. Fracture of the clavicle usually results from 
violent use of the fingers in extracting the after-coming head. The 
femur may be fractured from misdirected traction with fingers or fillet 
in breech delivery. Hsematoma of the sterno-cleido-mastoid muscle may 
result from artificial interference in breech extractions. A hard tumor 
about the size of a pigeon's egg may be seen developing in this muscle, 
usually on its anterior border. It is noticed between the ages of one 
and six weeks, and usually disappears by absorption in a month or so. 
The muscle fibres are sometimes torn. Haematoma of the sterno-cleido- 
mastoid may lead to contracture of the injured muscle and torticollis. 

Birth Palsies — Facial Paralysis. Injuries to the nerves during birth 
may be central or peripheral. The former injuries are, fortunately, 
the less frequent. 

Pressure upon the seventh or facial nerve at the stylo-mastoid fora- 



INJURIES OF THE NEW-BORN CHILI). 



611 



men by the blades of the forceps is usually responsible for facial paralysis. 
The affection is, in most cases, unilateral, and will not be noticed when 
the infant is at rest. When nursing or crying the palsy of the affected 
side is apparent. Recovery usually takes place spontaneously in a few 
weeks. If the paralysis does not disappear promptly, faradism may be 
employed. In rare cases the palsy is permanent. 

Duchenne's Paralysis. The next most frequent peripheral palsy is seen 
in the arm. Various conditions during birth may produce compression 
and injury of the nerves about the shoulder, such as severe pressure of 
the obstetrician's finger or the blunt hook in the axilla, hematoma of the 
sterno-cleido-mastoid, or fracture of the humerus with displacement of 
the fragments. The greatest number of upper-arm paralyses, generally 
known as Erb's or Duchenne's paralysis, occur after breech deliveries. 
The injury usually results from traction made upon the shoulder in the 
delivery of the head, or in bringing down the arm when it is found above 
the head, or upon the head in vertex deliveries, and is due, as a rule, to 



Fig. 358. 




Duchenne's paralysis. (Jewett.) 



stretching of the fifth, sixth, and seventh cervical nerves. Dragging 
the head or the trunk strongly to one side is usually responsible for the 
excessive traction upon the nerve trunks of the injured side. The deltoid, 



1 By courtesy of Dr. Wm. H. Haynes. 



612 l'ATHOLOGY OF THE PUEBPEEIUM. 

biceps, braohialis anticus, and supinator longus arc the muscles oftenest 
affected. In mild cases the paralysis may not be noticed for some weeks, 

while in severe ones it will usually be apparent at once. 

Diagnosis. The position of the arm is characteristic. It hangs 
helpless at the side and is rotated inward ( Fig. 358). As the triceps is 

not affected, the child can extend the forearm, but cannot Ilex it. After 
a few weeks the affected muscles show more or less atrophy, hut the 

child will generally begin to use the forearm. The diagnosis of Krb's 
paralysis is not, as a rule, difficult when seen during the first year. The 

peculiar position of the arm and the group of muscles involved are rarely 
met with in any other affection at this early age. 

PROGNOSIS. The prognosis will depend upon the severity of the 
symptoms and the time when the treatment is begun. Spontaneous re- 
covery takes place in some cases within two or three months. If there 
is but little improvement after this length of time, spontaneous recovery 
is not to be expected, and the case demands active treatment. In some 
cases partial paralysis may remain for several years or be permanent. 

Treatment should be begun as early as the third month, and should 
consist in frictions or massage and the persistent use of electricity. If 
the muscles react to the faradic current it may be used; but if not, the 
galvanic current must be employed. The treatment must be continued 
for several months, or until recovery is nearly complete. The foregoing 
treatment applies also in facial paralysis. 

Central Paralysis. A form of meningeal apoplexy, followed by hemi- 
plegia, is one of the results of prolonged and difficult labor. It has been 
supposed that the use of forceps is largely responsible for this accident, 
and the rough and careless use of instruments is doubtless a competent 
cause. The writer believes, however, that too long delay in the applica- 
tion of the forceps when the head is being subjected to prolonged press- 
ure is oftener responsible for this unfortunate accident. The careless 
use of ergot before delivery, by inducing a tetanic contraction of the 
uterus, also favors congestion of the foetal brain. 

Symptoms and Prognosis. The symptoms induced by meningeal 
extravasation depend, of course, upon the seat and extent of the effusion. 
The extravasation is frequently located over the motor convolutions, 
and if not extensive the hemiplegia may disappear with the absorption 
of the blood. If more extensive, however, the infant may be still- 
born, or, if living, it may soon die from asphyxia or in a comatose 
condition. Convulsions may occur shortly after birth, followed by 
coma. If death does not ensue the prognosis for the extremities affected 
is good, as the paralysis gradually improves, often undergoing complete 
recovery. The brain, however, may be irreparably injured, as shown by 
subsequent epilepsy or even by various degrees of idiocy. 

Treatment. The treatment must be preventive. This consists in 
avoiding as much as possible prolonged pressure upon the foetal head, in 
a careful use of the forceps, and in seeing that the infant cries imme- 
diately after birth, thus being assured that the lungs are inflating. It is 
of great importance that the transition from the foetal to the post-natal 
circulation should at once take place at birth, as otherwise great damage 
may be done, particularly to the brain ; the vessels here are fragile and 
easily ruptured. If the infant cries the expanding lungs draw off the 



INJURIES OF THE NEW-BORN CHILD. 



613 



excess of Jblood that may do damage elsewhere. The physician should 
give his first attention to the infant until this happens, as a short period 
of asphyxia may do incalculable harm. If the lungs do not act, it is 
well to let the cord bleed to the extent of a few drachms to prevent 
severe congestion of other vital organs. 

Asphyxia. The accidents during labor that induce asphyxia are: Sud- 
den death of the mother, constant pressure upon the umbilical cord, 
severe compression of any part of the foetal body, especially the head, 
as noted above, and more or less complete detachment of the placenta. 
In consequence of the air-hunger induced by these conditions, a vigorous 
infant may by inspiratory suction take in secretions of the birth-canal, 
which may cause suffocation after birth or induce pneumonia later. Very 
feeble infants may fail to establish respiratory movements after birth, 
owing to weak or defective muscles and nerves. In partial asphyxia 
there is congestion and suffusion of the skin, with blueness of the mucous 
membranes, full pulse, and moderate action of the reflexes. As the 

Fig. 359. 




Byrd's method— expiration. (Jewett.) 

symptoms of carbon-dioxide poisoning become more marked, the pulse 
grows feebler, the skin paler, and the mucous membranes assume a grayish- 
blue color. The reflexes are likewise lost. The prognosis in the latter 
condition is exceedingly bad. In the milder degrees of birth -asphyxia 
recovery usually ensues. 

The Preventive Treatment consists in measures addressed to the 
acceleration of tedious labors and the prevention of prolonged pressure 
upon the foetal parts, especially the head. During descent of the head 



614 



PATHOLOGY OF THE PUERPERIUM. 



malpositions of the cord, especially prolapse, or winding tightly around 
the neck, must be looked for, and, if possible, corrected. One of the 
possible causes of asphyxia will be removed if as soon as the head is 
born it is so turned thai the Pace shall not lie in a pool of blood and 
Liquor amnii. At the same time the mouth and fauces can hastily be 
cleaned of mucus with a moist rag drawn over the finger, or by means 
of a sofl rubber tube with a rubber bulb attached. In moderate degrees 
of asphyxia the stimulus of the cool external air, and allowing a drachm 
or two of blood to escape by the cord, will be sufficient. Should this 
not suffice the chest may be sprinkled with cold water to stimulate the 
reflexes, while the infant is held suspended by the feet for the purpose of 
allowing mucus to gravitate from the air-passages. The child may be 
plunged alternately into hot and cold water. The hot water should have 
a temperature not exceeding 105° F. When these external stimuli fail to 
excite respiratory movements, resort must be had to artificial respiration. 

Fig. 360. 




Byrd's method— inspiration. (Jewett.j 



The child's pharynx should first be cleared of mucus and other liquid 
material that may have been drawn into it by premature efforts at respi- 
ration. The simplest aud most effectual method of inflating the lungs 
is by direct insufflation — the raouth-to-mouth method. 

Direct Insufflation. The child is placed upon its back with the 
head extended by means of a small pillow or roll of clothing placed 



INJURIES OF THE NEW-BORN CHILD. 



615 



under its neck; the month is well cleansed and a towel or handkerchief 
is spread over the face. With one hand closing the nose, and with the 
other making pressure upon the epigastrium, to prevent the inflation of 
the stomach, the physician forces air from his own gently into the child's 
mouth and inflates the lungs. The air is expelled by gentle pressure 
upon its chest, and the process then repeated. When properly per- 
formed, this method is safer than passing a catheter or other instrument 
into the trachea, as is sometimes practised. Care should be taken lest 
injury be done to the air-cells by too forcible expansion. 

Byrd's Method is simple and efficient, and can be conducted without 
rough handling, a matter of no little importance. The child lies upon 
its back on the palmar surfaces of the operator's outstretched hands. 



Fig. 361. 




Schultze's method of artificial respiration— expiration. (Jetvett.) 

The operator by elevating the radial edges of his hands doubles the 
child's trunk upon itself — expiration (Fig. 359). Then by lowering the 
radial well below the level of the ulnar borders of the hands the child's 
trunk is thrown into a position of extreme extension — inspiration (Fig. 
360). 

The Method of Schultze is as follows : The operator holds the 
infant suspended, face to the front, his index-fingers being hooked in 
the axilla?, the thumbs resting on the front of the chest and the fingers 
upon the infant's back. The lower portion of the child's body is 
now swung outward, upward, and finally toward the operator's face, 






<;it; 



PATHOLOGY OF THE PUERPERIUM. 



inverting the position. Care Bhould be taken that the trunk ie most 
strongly flexed in the Lumbar region. In this position the thorax 



IG. 862. 




Schultze's method— inspiration. (Jewett.) 



is compressed — expiration (Fig. 361). The child's lower extremities 
are now swung outward away from the operator's body and down- 



INJURIES OF THE NEW-BORN CHILD. 617 

ward till the child hangs suspended by its axillae in the position first 
described. In this position of the child, hanging by its upper extremi- 
ties, the abdominal contents fall and the diaphragm sinks — inspiration 
(Fig. 362). Tc assist the respiratory movements the pressure of the 
operator's thumb is relaxed during inspiration and increased during 
expiration. This method is not to be recommended in feeble children. 

Laborde's Method. Laborde recommends rhythmical traction upon 
the tongue eight or ten times a minute as an effective method of estab- 
lishing respiratory movements. It has the advantage that it can be 
carried on while the child is kept in the warm bath, and it does not 
involve rough usage. 




Laborde's forceps for traction on the tongue of the new-born in the treatment of asphyxia. 
(After Ribemont-Dessaignes and Lepage.) 

Other Measures. It must be borne in mind that it is not enough 
that the child begins to breathe: it must be watched for some time to see 
that the respirations continue. It may be advisable in some cases to 
administer hypodermically ten to twenty drops of whiskey combined 
with 1 minim of tincture of belladonna or T ^- grain of strychnine. In 
most cases it will be necessary after resuscitation to apply dry heat 
by a hot-water bag or other means. In asphyxia pallida a rectal injec- 
tion of water at a temperature of 110° F. is of marked service. 

Atelectasis. Closely allied to asphyxia, and often associated with it, is 
a persistence of the foetal condition of the lungs, either of one or both in 
whole or in part. It is due to failure of the infant to completely inflate 
the lungs, and may persist for a considerable time. Sometimes it results 
in death, even after respiration had apparently been fully established. 

This is more apt to involve the lower lobes than the upper ones. It 
is frequently seen in premature infants with feeble respiration. The 
cause may also be injury to the brain from pressure. The symptoms 
are those of deficient respiratory action, such as pallor, feeble cry, and 
poor circulation, with very little expansion of the chest-walls over the 
affected area. Deep inspiration may be encouraged by artificial respira- 
tion, and the vitality conserved by the external application of heat and 
the judicious administration of nourishment and stimulants. 

Foetal Death must be distinguished from asphyxia. In the former 
the heart pulsations cannot be felt, and respirations and reflexes are 
absent. In the latter the heart is pulsating, reflexes are present, and 
there may be feeble attempts at respiration. We should not refrain from 
efforts at resuscitation because the heart-sounds are absent or no pulsa- 
tions can be felt in the prsecordial region. The distinction between a 
deadborn and a stillborn infant can usually be made by the rapid fall of 
rectal temperature in the former to ten or fifteen degrees below normal 



618 PA THOLOOY OF THE PUERPERIUM. 

and by the widely dilated condition of the pupils in the deadborn. One 
or two forcible inflations of the Lungs by the mouth-to-mouth method 
will usually cause the heart to pulsate in the stillborn, while it will have 
do effect on the deadborn. If the heart pulsates after this trial, a hypo- 
dermic injection of whiskey, n iv-.\, and strychnine, gr. T i , may be 
given and artificial respiration continued. 

Diseases of the New-born. 

Mastitis. The mammary glands of the new-horn infant often secrete 
a milk-like substance, which appears between the fourth and tenth days 
after birth. During this time there may be swelling of the glands, 

which gradually abates with the subsidence of the secretion until, usually 
by the twentieth day at the latest, both secretion and swelling have disap- 
peared. In some cases, however, the glands may remain engorged and 
tender, and suppuration ensue. This implies infection, and is exceedingly 
rare when proper antiseptic precautions have been observed during and 
after labor. 

Treatment. When there is simple swelling the parts may be cleansed 
with soap and water and bathed with a weak antiseptic solution, either 
of carbolic acid or bichloride of mercury. Gentle support with absorb- 
ent cotton and a bandage will also be indicated. If, in spite of this, 
suppuration occurs, there will be rise of temperature and the local signs 
of abscess. Then early incision, under proper antiseptic precautions, 
constitutes the treatment. 

Umbilical Hemorrhage. Hemorrhage may take place from the stump 
of the cord shortly after birth, from insecure ligation, from shrinkage 
of the funis, or from slipping of the ligature. Laceration of the cord 
between the abdomen and the ligature may atso be responsible for hemor- 
rhage. Secondary hemorrhage, usually between the fifth and fifteenth 
days, may occur, even though the cord has been securely ligated and 
properly watched. The trouble may be due to changes in the walls of 
the minute bloodvessels, allowing transudation, or to imperfect coagula- 
bility of the blood. In the latter case the hypogastric artery and the 
umbilical artery and vein have not been tightly occluded by the usual 
fibrinous plug. The hemorrhage is accounted for by syphilis, jaundice, 
haemophilia, or by depraved health on the part of the parents. 

Treatment. The great majority of cases are fatal from the impos- 
sibility of controlling the hemorrhage. In the milder ones a compress 
of lint tightly applied with adhesive strips may be sufficient. In more 
obstinate cases the lint may be saturated with a styptic, such as MonsePs 
solution. Dr. J. L. Smith recommends filling the umbilicus with a thick 
layer of plaster-of- Paris that is supported by the hand until it hardens, 
and then secured bv a bandage. In the most obstinate bleeding the 
umbilicus may be transfixed with two needles placed at right angles, and 
a figure-of-eight ligature be placed tightly around them. 

Umbilical Vegetations. Fungous granulations at times appear, arising 
from the floor of the umbilical fossa, shortly after the falling of the cord. 
They may attain the size of a pea, and they usually exude a bloody serum, 
which may induce excoriations in the surrounding skin. The granula- 
tions may gradually atrophy after weeks or months of sluggish existence. 



DISEASES OF THE NEW-BORN CHILD. 619 

The constant moisture and discharge is, however, a source of irritation, 
and it is best to destroy the growths. This can be accomplished by 
repeated cauterization with the solid stick of nitrate of silver, or, better 
still, by passing a ligature around the base of the mass and amputating 
the exuberant granulations with scissors. A dry dressing of boric acid, 
subnitrate of bismuth, or iodoform may then be applied. 

Umbilical Hernia. There may be an incomplete closure of the umbilical 
ring from defective development of the abdominal wall, with resulting 
protrusion of abdominal viscera at this point. Tendency to protrusion 
must be corrected at once by the constant application of a pad or truss. 
If this is not sufficient, or if the rupture increases rapidly in size, imme- 
diate operative interference is demanded. 

Icterus Neonatorum. Icterus is a common affection of the new-born. 
Two distinct varieties are recognized, differing widely as regards causa- 
tion and prognosis, and known as the mild and the grave forms. 

Mild Form. Two divergent theories have been advanced to account 
for this form. The first considers the jaundice to be purely haematic; 
the second theory regards it as hepatic in origin. Bile is first formed in 
the liver, and then carried into the circulation, the resorption being due 
either to congestion or to oedema of the hepatic tissue. It seems highly 
probable that both these theories may apply in different instances, and 
doubtless many cases of icterus neonatorum are to be satisfactorily 
explained only by taking into consideration a morbid condition of both 
the blood and the liver, thus combining the haematic and hepatic theories. 

The intense congestion of the skin observed during the first few hours 
of life often produces a yellowish coloration that cannot be considered 
jaundice. It is of the same nature as the discoloration of the skin fol- 
lowing an ordinary cutaneous bruise. The yellow tint is at first seen 
only on deep pressure, but as the erythema fades the yellowness increases. 
The conjunctivae are not colored, and the urine appears normal. This 
yellowness is usually first noticed on the second day, and may continue 
a few days or a week. 

The term " true icterus" can be applied only to those cases in which 
the yellow discoloration of the skin is caused by a staining by the bile 
pigments. This more often occurs in cases of prolonged or difficult 
labor, in children born asphyxiated or before term, and in generally 
feeble infants. It is very frequently seen in foundling asylums. It 
may appear as early as a few hours after birth, but usually is not marked 
until the second or third day. In very mild cases the yellow color 
may appear only on the face, chest, and back, the conjunctivae being but 
faintly tinted and the urine and feces normal in appearance. In severer 
forms the urine may be high-colored enough to stain the linen, and the 
jaundiced hue may extend to the arms and abdomen. Some infants pre- 
sent a yellowish discoloration of the whole body, with typical clay-colored 
stools. In most cases the jaundice has disappeared by the eighth or tenth 
day. It may, however, persist for several weeks. In rare cases, after 
having much diminished, it reappears with renewed intensity. No 
matter how extensive this form of jaundice may be, it causes very little 
constitutional disturbance. The liver may be slightly enlarged, and occa- 
sionally there are symptoms of intestinal catarrh. A few small doses of 
calomel or mercury with chalk will be all the medication required. 



620 PATHOLOGY OF THE PUEBPEBIUM. 

Grave Form. This form is, fortunately, rare, and may be produced 
by several different conditions. Defects in the bile-ducts will first be 
mentioned as among the commonest causes. In some cases all the large 
bile-duets have been absent; in others the ductus communis choledochus 
has been nan-owed, obliterated, or entirely absent. Sometimes a fibrous 

cord has been found in place of the gall-duct. The cystic duct bas been 
absent and the gall-bladder in a rudimentary condition. Accompany- 
ing an obliteration of the gall-ducts cirrhosis is usually found in the 
liver, which will be more or less marked, according to the length of 
time the infant survives. The liver is generally enlarged. Jaundice 
that is due to obstruction or obliteration of the biliary passages may 
appear a few hours after birth, and soon acquire a marked intensity. It 
often, however, does not appear for one or two weeks after birth. The 
yellowish discoloration of the skin may vary from day to day, at times 
being much more intense than others. The conjunctivae are yellow. The 
fecal discharges lose color and have an offensive odor, while the urine 
stains the napkin a yellow or greenish-brown. The spleen, as well as the 
liver, is usually enlarged, which partially accounts for the increase in 
size of the abdomen. Umbilical hemorrhage is a grave and not infre- 
quent symptom in this form of jaundice. The bleeding is not sudden 
and profuse, but begins as an oozing shortly after the separation of the 
navel string. It is apt to commence at night. Death is always hastened 
by this accident, and exhaustion from loss of blood is added to that 
induced by indigestion and malassi nidation. There may also be a species 
of general purpura, bleeding taking place from the nose, mouth, or 
stomach. Infants may live for several months with impervious or 
defective bile-ducts, though death usually takes place earlier, from fail- 
ure of nutrition. 

Another form of grave icterus neonatorum is observed in connection 
with certain inflammatory changes in the liver, usually taking the form 
of an interstitial hepatitis, with which may be conjoined inflammation of 
the biliary canals. This lesion is apt to be one of the results of congen- 
ital syphilis, as is likewise perihepatitis, which may cause a complete 
obliteration of the biliary passages. The latter form of inflammation 
often involves the connective tissue surrounding the common duct, the 
portal vein, and the hepatic artery on the under surface of the liver. 
These cases, however, may not always be of syphilitic origin. Perhaps 
the commonest manifestation of the grave form of icterus in the newly 
born is seen in connection with septic poisoning — that is, generally accom- 
panied with phlebitis. This will be considered under the head of sepsis. 

Umbilical Infection. The umbilicus is the most vulnerable spot for the 
entrance of septic poisons during or shortly after birth. Upon ligation 
of the cord the blood that remains in the umbilical veins forms small 
thrombi that should gradually harden, and in time become calcified, 
forming a fibrous cord in the same manner as in the ductus arteriosus 
and ductus venosus. In these latter structures the formation of thrombi 
is never accompanied with grave consequences, since their internal situa- 
tion prevents the access of infectious agents. Pyogenic organisms, how- 
ever, can readily gain access to the umbilical vein, and give rise to 
umbilical phlebitis and septicaemia. 

There is a constant alteration after birth in the blood-pressure in the 



DISEASES OF THE NEW-BORN CHILD. 621 

umbilical vein, due to the action of the heart and lungs, by which a sort 
of flux and reflux is produced. This favors infection of the system 
when the contents of this vein become septic. 

This grave accident is liable to occur when the mother is in a septic 
condition. The poison may be produced by the same agents that have 
caused the puerperal fever. In these cases of sepsis there is a puri- 
form or yellow softening of the thrombi that fill the umbilical vein. 
The softened matter consists of pus-corpuscles and finely granular matter 
containing micrococci. This sets up an inflammation not only in the 
vessel itself, but also in the surrounding tissues. Infective emboli may 
be carried to various parts of the body. As the micrococci enter the 
umbilical vein from the umbilical fossa, owing to the perviousness of this 
vessel, the structures near at hand, especially the liver, bear the first brunt 
of the septic inflammation. The latter organ is usually found much dis- 
eased or degenerated. There is severe jaundice, with constant elevation 
of temperature. and other symptoms of general septic infection. If the 
infant lives long enough peritonitis will probably develop, and sometimes 
empyema or even meningitis. In all cases evidence of severe illness 
and prostration are present. Cutaneous, mucous, or visceral hemorrhages 
may supervene at any time. The abdomen is generally swollen and 
tender, and dirty-looking pus may be seen oozing from the navel; slight 
pressure about the umbilicus will often cause pus to exude if it is not 
otherwise apparent. The fecal discharges may be of natural appearance, 
but the urine is usually highly colored. The infant refuses nourishment, 
and there may be vomiting of greenish matter. Severe nervous symp- 
toms, such as convulsions or coma, supervene before death. While the 
umbilicus is the most common seat of septic infection, any sore or abra- 
sion elsewhere may afford entrance to germs. Erysipelatous eruptions 
on the abdomen, chest, or other parts, are the most frequent manifesta- 
tions of such infection. 

Treatment. The prophylactic treatment of sepsis consists in the 
careful antiseptic management of labor and proper attention and clean- 
liness in reference to the navel. Localized sepsis may be combated by 
the topical use of peroxide of hydrogen, bichloride of mercury solution, 
or other strong antiseptic agents. 

The remedial treatment of systemic infection consists in full stimula- 
tion and general support and the judicious use of external refrigerant 
measures. In the latter condition, however, treatment is generally futile. 

Conjunctivitis. The conjunctival membrane in the newly born is very 
sensitive, and frequently the seat of inflammation. A mild catarrhal 
inflammation is often seen, unattended by swelling of the lids, the inner 
surface being reddened and covered with a slight viscous secretion. The 
eyes must be kept cleansed by frequent bathing or irrigation with a satu- 
rated solution of boric acid. A little vaseline may be applied to the lids 
to prevent retention of the secretion by adhesion of their edges. 

Ophthalmia Neonatorum. This form of purulent conjunctivitis may 
be due to infection by the gonococcus or by various pyogenic cocci. 
The former is the infecting agent in about 36 per cent, of cases. If 
the disease manifests itself by the second or third day, the infection 
probably took place during birth. When there is a delay of a week 
or more, however, the virus has probably been conveyed by careless 



622 /'l T11OL0GY OF THE PUERPERTUM. 

attendants, by soiled fingers or other infected objects. The inflammation 
is of an intensely virulent type, involving both the ocular and palpebral 
conjunctiva. The sac is filled with a grayish muco-purulenl secretion, 
and there is intense chemosis. The subconjunctival connective tisane 
and skin are much swollen, so that the eye can only with difficulty be 
opened. There are photophobia, pain in the eye, and rise of temperature. 
Unless the symptoms quickly subside, the eye is irreparably damaged 
by ulceration and partial destruction of the cornea. The inflammation 
begins in one eye, but soon attacks the other unless it is effectively pro- 
tected. 

The Prophylactic Treatment consists in employing antiseptic 
vagina] douches in the parturient woman when there is any muco- 
purulent discharge, and dropping two or three drops of a 2 per cent. 
solution of silver nitrate into each eye immediately after birth, after the 
method proposed by Cred6. 

Curative Treatment. When the inflammation has actually begun 
the eye must be kept as free of pus as possible by constant washings with 
a saturated solution of boric acid. The swelled and puffy lids should 
have applied to them every few minutes pledgets of sheet lint that have 
been kept upon a cake of ice, and the pus must be removed every hour 
or two. Constant cleansing and cooling of the surface will require the 
services of a careful nurse night and day. A 2 per cent, solution of 
nitrate of silver, or of bichloride of mercury one or two grains to the 
pint, may be instilled between the lids every two or three hours, accord- 
ing to the severity of the case. As this affection so frequently results in 
blindness, it is well, if possible, to have the advice of an oculist. Pro- 
targol in 10 per cent, solution has been recently recommended as a sub- 
stitute for nitrate of silver. It has the advantage of being less painful, 
and is said to be equally efficient. 

Tetanus Neonatorum. Although this disease is distributed through a 
wide geographical area, it is most apt to be found in filthy surroundings. 
Something beside filth, however, is necessary; there must be a specific 
cause. This consists in the tetanus bacillus, of the pin-head and bristle- 
shaped form. It may exist in straw or dust from hay, which explains 
the fact that horses are subject to tetanus, and that traumatic tetanus is 
often seen among laborers who are employed about farms and stables. 

The disease usually begins during the first ten days of life, and the onset 
is apt to be preceded by great fretfulness. Disinclination to nurse is soon 
followed by rigidity of the voluntary muscles, usually starting in the 
masseters. The rigidity increases, reaching its maximum in from twelve 
to twenty-four hours. The head is thrown back, and there is a general 
flexion of the extremities. One peculiarity of the disease is that while the 
toes are flexed the great toes are adducted. There may be some relaxa- 
tion at times, especially during sleep, but there are constant exacerbations, 
provoked by any peripheral irritation. Respiration and circulation may 
be extremely embarrassed, and opisthotonus may be present during these 
exacerbations. 

Treatment. While the specific cause of the disease may gain entrance 
at any point of the body when the necessary lesion exists, the umbilical 
wound is undoubtedly the seat of infection in the great majority of cases 
of tetanus neonatorum; hence the utmost cleanliness must be observed 



DISEASES OF THE NEW-BORN CHILD. 623 

in cutting the cord and in dressing it. The scissors, the ligature, and 
the entire management of the navel, cord, stump, and the umbilical 
wound must be rigidly aseptic. The excess of the gelatinous matter 
should be stripped from the cord, and a dry, antiseptic dressing applied. 
Speedy mummification of the stump is the best safeguard against infec- 
tion. Special care must be exercised in the umbilical dressings where 
the dwelling is easy of access to stable-yards containing horse-manure or 
loose earth. 

When the disease is once established it is almost invariably fatal. In 
cases of suppuration at the umbilicus, frequent cleansing with a solution 
of mercuric bichloride of suitable strength should be employed. With 
reference to drugs, the two most valuable are potassium bromide, gr. iv 
every two to four hours, and chloral hydrate, gr. j every hour. Sul- 
phonal, gr. iij every two hours, by the rectum, has been recommended. 
While these are administered the infant must be given nourishment 
frequently, and stimulants should be freely employed. The difficulty of 
swallowing, however, is a source of embarrassment in satisfactorily car- 
rying out these measures. A tetanus antitoxin is now produced by 
several manufacturing chemists, but so far little experience has been 
reported in the serum treatment of tetanus neonatorum. 

Tubercular Infection. Tuberculosis is very rare in the newly born, and 
is not common in the first year. It has been disputed that the foetus 
can be infected by tubercle bacilli in the uterus, but the evidence seems 
to show that such infection may occasionally, though rarely, take place. 
Acute miliary tuberculosis, however, may develop within the first few 
days of life. In very early life the lymph tracts and bones are espe- 
cially liable to tubercular infection. The prominent symptoms are 
irregular fever, rapid wasting, and prostration. Increased frequency of 
respiration and bronchial rales are present, but the infants usually die 
from a general infiltration of all the organs with fine, miliary tubercles 
before they have time to localize sufficiently in any one organ to be 
detected by physical signs. 

Syphilis. This disease may be acquired from the father or mother, or 
from both parents, the poison being conveyed by the spermatozoa of the 
male or the ovum of the female. While it has been denied by some 
observers that the father alone can transmit syphilis, the consensus of 
opinion is in favor of the possibility of such transmission. Without 
antisyphilitic treatment the spermatozoa can usually convey the syphilitic 
poison during the first year after primary infection, and there is great 
danger to the foetus from syphilitic contagion up to the fourth year. 
The influence of the mother upon the growth and development of the 
foetus contained within her uterus is obviously very great, and when she 
is suffering from constitutional syphilis the disease is transmitted in an 
active stage to her child. The degree of such transmission depends, as 
noted above in the case of the father, upon the stage and severity of the 
disease and the nature of the treatment employed. During periods of 
latency the mother may bear healthy children, followed by abortions or 
syphilitic infants caused by renewed manifestations of the disease. It 
has been considered that the power of transmission is practically lost at 
the end of six years. 

Collet Law. In 1837 Colles wrote that "A new-born child affected 



624 PATHOLOGY OF TSE PUEBPEBIUM. 

with inherited syphilis, even though it may have the specific lesions in 
the mouth, never causes infection of the breast which it -neks if it be 
the mother who nurses it, although continuing capable of infecting a 
Btrange nurse." The substantial truth of this dictum has not been 
seriously questioned, though various explanations have been offered. 

When the virus of the disease is concentrated, as in cases where hoth 
parents are syphilitic, the foetus will he attacked by the disease in the 
uterus, and, as a result, abortion will occur more or less early in the 
pregnancy. As the disease abate- in one or both parents the pregnancies 
will be Longer in duration, until, at last, apparently healthy infants mav 
be born. In some cases the infant will present marked evidences of 
syphilis at birth; often, however, the onset is delayed until later, and at 
birth there may be absolutely no manifestation of the disease. The 
earlier the disease shows itself after birtli the graver will be the nature 
of the attack. 

Very early syphilis is usually accompanied by emaciation, eruptions 
of bullae, particularly upon the palms of the hands and soles of the 
feet, and an extreme degree of coryza, cracked and ulcerated lips, and 
evidences of visceral and bone disease. In the older cases there may be 
no interference with nutrition, and possibly one or two mucous patches 
may be the only active evidence of the infection. 

Treatment. The treatment may be local or internal. Daily inunc- 
tions of mercurial ointment mixed with from four to eight times its 
quantity of vaseline or rose ointment are efficacious. It may be rubbed 
on the inside of the thighs or in the axillae, using a portion about the size 
of a hickory-nut. A more cleanly method of local medication consists 
in applying five drops of a 10 per cent, solution of oleate of mercury 
three times daily. Mercury with chalk may be internally administered, 
in doses of \ grain to 1 or 2 grains twice daily. Calomel has a more 
rapid action in doses of from -fa to \ grain three times a day. Parents 
who exhibit evidence of syphilis or who have had syphilitic children 
should be subjected to full specific treatment. 

Thrush, or Sprue. This is a disease liable to make its appearance during 
the first or second week after the birth of an infant, especially when clean- 
liness of the mouth, bottle, or nipples is neglected. It is a parasitic dis- 
ease, characterized by the appearance of small white patches or flakes on 
the tongue, inside the cheeks, or on the palate. The parasite which 
produces sprue is a fungus consisting of a mycelium network resem- 
bling the moulds and spores. These spores are to be found in the air 
at all times, and they grow in the mouth only in a pathological condition 
of the epithelium, such as catarrhal inflammation or uncleanliness. The 
fungus belongs to the saccharomycetes, or sugar-fermenting organisms. It 
has received the name of saccharomyces albicans, and was formerly known 
as the oidium albicans. When examined with a low-power microscope, 
the white patches are found to consist of small threads and small oval 
spores. With a higher power the threads are shown to be made up of 
small rod-like segments connected together at the ends. From these 
shorter rods the spores are developed. These spores when placed in 
suitable conditions germinate and produce the thread or mycelium. They 
exist in the atmosphere, and when they are deposited upon a mucous 
membrane previously irritated or the subject of catarrh, they grow, pro- 



DISEASES OF THE NEW-BORN CHILD. 625 

ducing the patches above described. The growth usually begins at 
many isolated points in the mouth and spreads out into larger patches, 
which often coalesce, forming a more or less continuous membrane. 
Almost the whole of the tongue, cheeks, and hard palate may become 
covered with this membrane. It may even extend to the soft palate and 
pharynx, but rarely into the stomach or intestines. 

Symptoms and Diagnosis. The appearance of the white patches in 
the mouth of the infant, firmly adhering to the membrane, is sufficiently 
characteristic to make the diagnosis easy and certain. The mucous mem- 
brane of the mouth is usually dry. If the patches be forcibly removed, 
the mucous membrane beneath appears red, and will frequently bleed. 
When these deposits appear upon the tonsils or soft palate they may be 
mistaken for diphtheritic exudate, a mistake which is hardly possible 
if all the symptoms are taken into consideration. The disease is not 
in itself a dangerous one, and in many cases it should be regarded only 
as a symptom of debility or inanition. 

Treatment. Most important is prophylaxis. Careful attention to 
cleanliness of the mouth, nipples, bottles, clothes, etc., will usually pre- 
vent the occurrence of sprue. The infant's mouth should be carefully 
cleansed several times a day with some mild antiseptic solution, as boric 
acid or sodium salicylate slightly sweetened with glycerin. 

On the first appearance of the white specks or patches in the mouth 
of an infant, it should be washed after each nursing with a 3 per cent, 
solution of hydrogen dioxide, sweetened with glycerin, or a solution of 
sodium benzoate or sodium salicylate, ten grains to the ounce. The 
popular solution of borax and honey is objectionable, since the honey 
feeds the ferment and causes it to grow more rapidly, while the borax 
is not a sufficiently active antiseptic to prevent it. 

The nurse should be cautioned against using harshness in washing the 
mouth, lest she make it sore. ISTo attempt must be made forcibly to 
detach the membrane. If the child is nursed at the breast, the nipples 
should be washed with one of the above antiseptic solutions after each 
nursing; if artificially fed, the rubber nipples must be thoroughly disin- 
fected after using. 

Indigestion and colic are frequent complications of sprue. The pas- 
sages become green and slimy and contain undigested curds and fats. 
It is quite probable that the swallowed ferment leads to acid fermentation 
in the stomach or intestines, with the production of excessive acidity of 
the stools, and frequently the appearance of troublesome erythema of the 
nates. The gastro-intestinal disorder, as well as the primary affection, 
will need careful attention. With proper treatment the disease is easily 
managed. 

Colic. This is a common affection of the new-born infant. The pain 
is usually the result either of flatulence or excessive acidity, due to 
indigestion and acid fermentation. Usually the paroxysms come on at 
certain hours of the day, with intervals of complete or partial freedom 
from pain. It is more prevalent in artificially fed infants than in those 
nursed at the breast. Once established in early infancy it usually con- 
tinues with more or less severity for two or three months. The impor- 
tance, therefore, of careful attention to the food and the feeding of infants 
during their first week becomes self-evident. 

40 



626 PATH01 )QY OF THE PUERPERIUM. 

[ntestinal fermentation, or decomposition <>f the food or of the intes- 
tinal mucus, with the production of gas and distention of* the bowels, is 
almost uniformly present. This distention and the irritation of the 
mucous membrane by the products of the fermentation induce spasm of 
the muscular fibres of the intestinal walls, which is the immediate cause 
of the ]>ain. 

The most frequent cause; of infantile colic is overfeeding during the 
first two or three days after birth, or feeding with improper foods. 

When the infant is to be nursed by its mother, no other food should 
be given, unless the mother's milk is manifestly delayed or abnormally 
deficient. If the child is to be artificially fed, no other food should be 
allowed than that prescribed by the attending physician. Milk sugar, 
however, dissolved in water, may be given without harm. In most 
cases the bottle-fed infant is nursed upon the breast for the first week, 
unless deformed or sore nipples prevent. In beginning the artificial 
feeding of infants, nature's method should be followed as nearly as 
possible. During the first three days small quantities only should be 
given. The table on page 287 will serve as a guide to the quantity and 
frequency of meals. 

The cause is occasionally to be found in some abnormality in the quality 
of the mother's milk, the most frequent, during the first and second 
weeks of lactation, being the persistence of a high percentage of proteids, 
which we have seen to be characteristic of colostrum. In such cases the 
infant's stools are usually copious, frequent, and thin in consistency, and 
may or may not contain undigested masses of curd. A microscopic 
examination of the milk will reveal the peculiar corpuscles of colostrum. 
When the fat is excessive, the child will usually vomit after nursing, and 
the stools will contain excess of fat. 

Diagnosis. It must be remembered that crying is not necessarily due 
to colic. Often the cause is need of food. The cry of hunger is usually 
more constant than that of colic, which is intermittent and paroxysmal. 
It is not so violent, the child rather fretting than crying, and is quieted 
by feeding, while the cry of colic is usually rather aggravated than 
relieved by feeding. The pain may be due to other causes than colic. 
There is usually, however, little difficulty in distinguishing between colic 
and other forms of pain. The cry of colic is usually intermittent and 
violent, the child drawing up its knees during the paroxysms, the ab- 
dominal muscles being at the same time tense, and the abdomen usually 
full and tympanitic. Infants who suffer with colic usually appear to be 
hungry most of the time, and, consequently, are often overfed. 

Treatment. The treatment of colic is both palliative and curative. 
It is doubtful if much benefit is derived from carminatives, such as 
anise, fennel, chamomile, gin, etc. 

Better results are secured usually by enemata of warm water or by 
irrigations of the colon, especially when the stools are fetid. A pint of 
warm water injected high up by means of a double soft rubber canula 
may be used as an irrigant twice daily with great benefit. An injection 
of three or four ounces of warm water, with half an ounce of glycerin, 
rarely fails to excite peristalsis with the expulsion of the gas. 

Friction applied to the abdomen, following the course of the colon, 
is sometimes useful. Heat applied by means of warmed dry flannels 



DISEASES OF THE NEW-BORN CHILD. 627 

wrapped about the body or legs, or by holding the bare feet near a warm 
stove, is sometimes beneficial. 

The most useful of drug measures is one grain of chloral hydrate 
dissolved in a teaspoonful of anise-water, and given once to three times 
daily. It checks fermentation and quiets the nervous system without dis- 
turbing digestion. Five to ten drops of chloroform-water given every 
hour or two is often efficient in relieving the pains. Milk of asafoetida, 
3j by the mouth, or §j by the rectum, is a valuable remedy. 

The curative treatment must be addressed to the digestion. The 
most common cause of the affection in hand-fed infants is overfeeding. 
Next to this is feeding improper food. Great care is necessary in 
adapting the food to the needs and power of digestion of the new-born 
child. It is well to bear in mind that the most frequent cause of colic, 
as regards the quality of food, is an excess of sugar or casein. An ex- 
cessive amount of fat may, though rarely, be the cause of colic. The use 
of farinaceous foods must be prohibited. If the passages are excessively 
acid and the nates are erythematous, antifermentatives and antacids are 
indicated. Calomel in one-twentieth -grain doses, with one grain each of 
sodium benzoate and chalk, may be given every two hours. 

The stools must be carefully examined for excessive acidity, fatty acids, 
or fat, and for undigested casein, and the food modified to suit the indi- 
cations here given. White, yellowish-white, or grayish lumps in the 
stools may consist of fat, fatty acids, or casein. Fat and free fatty acids 
dissolve in ether, while casein does not. 

The following paste has been found useful by the author as an 
antacid and antifermentative laxative remedy in the treatment of colic 
attended with constipation : 

Oleiricini gss. 

Magnesii carbonatis 5ij. 

Sodii benzoatis . , 5ss. 

Sacchari lactis 3ij. 

Oleianisi gttv.— M. 

Sig. Teaspoonful once or twice a day. 

Strict regularity in the quantity and quality of food and frequency 
of feeding and scrupulous cleanliness must be insisted upon. The tem- 
perature of the food is also a matter of importance. If the food be 
given too hot or too cold, it may cause colic. Digestive or nervous dis- 
turbances in the mother, which may cause colic in the nursing infant, 
must receive attention. 



PART VIII. 

OBSTETRIC SURGERY. 



CHAPTER XXIX. 

IMMEDIATE REPAIR OF VAGINAL AND VULVAR LACERATIONS 
AND OF THE LACERATED CERVIX. 

IMMEDIATE REPAIR OF VAGINAL AND VULVAR LACE- 
RATIONS. 

Without a thorough knowledge of the anatomy and physiology of the 
structures concerned, it is impossible to arrive at a scientific method 
of treating the various injuries to which the vaginal outlet is subjected. 
It must be remembered that the normal outlet of the vagina is not a 
gaping orifice, but in the virgin, as she stands erect, appears externally 
as a mere slit, lying immediately under the vestibule beneath the pelvic 
arch. In a woman who has born children the outlet may be slightly 
relaxed without producing any serious consequences, but all marked 
grades of relaxation must be regarded as pathological. It was formerly 
thought that the wedge of tissue represented by the perineal body, like 
the keystone of an arch, formed the main support of the pelvic contents. 
As a matter of fact, the perineal body in itself has very little to do 
with keeping the organs in position. Again, it has been recently 
demonstrated that the levator ani muscle can hardly possess the func- 
tions assigned to it in this connection, but that the all-important struct- 
ures are the fascial sheets of the pelvic floor. 

On inspection it will be noticed that both the vaginal outlet and the 
anus are situated well forward, the former being under the pubic arch. 
The index finger, when introduced into the vagina, will feel the pubic 
arch above and to the sides, while as it is passed backward it impinges 
upon a resilient band of tissue stretching across the floor of the pelvic 
outlet from one pubic ramus to the other. By making continued firm 
pressure upon the posterior wall of the vagina a marked relaxation of 
this band is produced, together with a definite descent of the pelvic floor, 
which recovers its former position as soon as the pressure is removed. 

The recent work of Browning has shown that the levator ani muscle, 
from its insertion into the perineal body, the external sphincter ani, the 
postrectal raphe and the coccyx, pulls forward and upward the post- 
vaginal structures of the pelvic floor. (Figs. 364 and 365.) But the same 
author has shown that in a case examined by him shortly after the expul- 
sion of an eight months' foetus there was no evidence of stretching of the 
fibres of this muscle. Again, he argues that it is unphysiologic for a mus- 
cle to furnish a continuous support. The recto- vesical fascia lies above 

(629) 



630 



OBSTETRIC SURGERY. 



the Levator ani and sends processes to the bladder, vagina, and rectum. 
Browning denies thai this latter structure is merely a pari of the sheath 
of the muscle, and Is of the opinion that, when intact, it is sufficient by 



FlG. 864. 




^rv^c ^^U^ <U 



Dissection of pelvis, from above. (Savage.) 
a. sacrum. 6. urethra, c. vagina, d. rectum, e. levator ani. /. coccygeus. g. obturator internus. 

itself to afford all the support required to hold up the pelvie contents. 
The recto-vesical fascia consists of the two layers of the triangular liga- 
ment, the superficial fascia and the ischioperineal fascia. Of these, the 
last named is the most important in supporting the pelvic contents. 
A perineal tear that permits gaping always involves these sheets. When 
the ischio-rectal ligament is torn, the pelvic floor sags. But although it 
is possible that the part played by the levator muscle in supporting 
the pelvic contents may have heretofore been exaggerated, it is evident 
that, when it is torn, its restoration as nearly as possible ad integrum 
will always be of the highest importance to the patient, and the condi- 
tion of this muscle should always be taken into consideration in the 
treatment of perineal laceration. 

Character of the Injury. Injuries to the vaginal outlet occur generally 
during parturition. Consider for a moment what happens when a moder- 
ate-sized child comes into the world. Through an orifice which is nor- 
mally from 2 to 3 cm., about an inch, in diameter passes a child's head 
which dilates the outlet until it forms a ring 33 cm., 13 inches, in circum- 



REPAIR OF VAGINAL AND VULVAR LACERATIONS. 



631 



Fig. 365. 




Levator ani and coccygeus, seen from 
without, after removal of part of hip bone 
and clearing out of ischiorectal fossa. 
(Luschka.) 

a. Fibres of levator ani on vagina. &. 
Anus, with sphincter. 



ference. It is true that this distention when brought about gradually 
and equably by repeated advance and recession of the foetal head may 
be accomplished without injury, but it not infrequently happens that 
the delivery is somewhat precipitate, 
and, instead of gradual stretching, we 
have rupture of muscular fibres or 
fascial attachments. 

The outlet, when compared with the 
capacious vaginal cavity within the 
pelvis, may be likened to the narrow 
vent of a funnel with a wide mouth. 
It would seem surprising that so com- 
paratively small a passage is not more 
frequently injured during the birth of 
the head and shoulders of a child of 
ordinary size. 

Injuries of the vaginal outlet due to 
parturition may be divided into three 
classes : 

1. External or superficial tears. 

2. Internal or combined external 
and internal incomplete tears. 

3. Complete tears. 

1. The superficial external tear be- 
gins at the introitus and extends back- 
ward, involving the superficial portion of the wedge of lax tissue behind 
it. The rupture may extend inward beyond the hymen to the side of 
the posterior vaginal column, which normally lies in close proximity to 
the vaginal outlet, but which during parturition, when the tissues are 
put upon the stretch, is found much further back. 

So long as a tear does not in any way affect the supporting structures 
the injury done to the outlet is relatively unimportant. A few super- 
ficial stitches are necessary in order that suppuration, granulation, and 
the formation of sensitive scar-tissue may be avoided. (Fig. 366.) Rup- 
ture of the fourchette is the rule, even in normal labors, and need not 
be repaired ; but when the tear has a base of 2-3 cm., f-1^- inch, 
sutures are necessary. The patient should be placed with her body across 
the bed, the buttocks being made to overhang the side ; the legs are 
flexed upon the thighs, and the thighs in turn upon the abdomen, the 
position being maintained by assistants or by means of a leg-holder. 
The labia having been drawn apart, the raw surfaces can be made out 
as two triangular areas separated at their apices, which are formed by 
the divided fourchette, and united at a common base. 

The instruments required are (1) a needle-holder, (2) a small curved 
needle, (3) a few silk or catgut sutures 22 cm. (8 inches) in length. 

The lips of the tear being held apart by the index and second fingers 
of the left hand, the needle is introduced near the upper angle of the 
tear about half a centimeter, ± inch, from the margin. After having 
been brought out in the bottom of the tear, it is re-entered near this point, 
and emerges on the skin surface on the opposite side at a point corre- 
sponding to that of its first entrance. The next suture having been 






632 



OBSTETRIC SURGERY. 






passed Dearer the lower angle of the tear, both are tied, and the wound 
is almost completely closed. Two or three superficial sutures may be 
required t<> complete the approximation. During 
convalescence care should be taken not to make 
pressure upon the approximated surfaces with the 
tinker or with the nozzle of the syringe, r~li< »uKl a 
douche need to be given. The stitches may 1><' re- 
moved about the eighth day. To do this the but- 
tocks and labia are separated with the fingers and 
thumb, and the surface of the wound i- cleansed by 
means of" pledgets "f cotton saturated with boric acid 
solution ; each suture, being caught in the dressing- 
lbreeps, is gently pulled forward until the loop is 
exposed, so that it can be cut close to the surface. 
The suture is withdrawn by making traction upon 
the end containing- the knot, so that the smooth por- 
tion is drawn through the tissues. 

2. Combined Internal and External Tear. In the 
second form of laceration the injury sustained during 
labor may appear as a gutter-shaped tear, which is 
generally in the median line on the skin surface, but 
within the vagina involves either one or both of the 
lateral sulci of the vagina. The laceration may vary 
in length from 2.5 to 5 cm., 1 to 2 inches, or may be even longer. It 
may be caused by pressure of the head or of the shoulder, the former 




Superficial tear ex- 
posed by fingers parting 
labia minora. 




Superficial combined internal and external tear, showing portion of tear in vagina that may 

escape notice. 

in its descent producing a tear inside the vagina which may be further 



REPAIR OF VAGINAL AND VULVAR LACERATIONS. 



633 



Fig. 368. 



enlarged by the shoulder of the fetus as it forces its way down between 
the levator fibres and their rectal attachments on one or both sides. In 
addition we generally have a super- 
ficial rupture of the fourchette. It 
not infrequently happens that this 
latter portion of the tear is the only 
one attended to, and that the most 
important part, being concealed with- 
in the vagina, escapes notice. (Fig. 
367.) It is, however, the main in- 
jury to the supports of the vaginal 
outlet which should more especially 
be sought out and remedied. Imme- 
diate repair should be instituted. 
(Fig. 368.) 

Method of Operating. The 
method of operating for the closure 
of recent internal tears is somewhat 
as follows : The patient should be 
placed in the position just mentioned 
when describing the suturing of a 
superficial laceration ; the perineal 
drainage cushion (Fig. 366) should 
be placed under the buttocks, with the apron over the edge of the bed 




Patient in lithotomy position, on perineal 
pad, ready for the immediate operation. 



Fig. 369. 





Combined internal and external tear. 

hanging into a bucket. In these cases it is generally better to give an 



63 I 



OBSTETRIC SURGERY. 



anesthetic, unless the patient Is oonfidenl that she can bear a moderate 

amount of |>ain. 

The following instruments should be in readiness: 

1. Needle-holder. 

2. Small and inediiini->ized curved 
needles threaded with carrier-. 

3. Six strand- of silkworm-gut. 

4. One dozen medium-sized silk or 
catgut sutures. 

5. Emmet's curved scissors, and the 
Sims' or Simon's speculum or a Hat 
retractor. An Emmet's needle is by 
some operators preferred to the usual 
surgical needle. (Fig. 371.) 

The anterior wall of the vagina being 
held back and the labia separated by the 
fingers of the left hand (Fig. 366), or by 
means of a speculum or retractor in the hands of an assistant, and the 
upper angles of the wound having been thus exposed, the first suture is 
passed just below the upper angle of the tear, and the next about a centi- 
meter below this, and so on down to the other extremity. The needle 
should be introduced 5 mm. or more from the margin of the wound, 
since otherwise, if there is much contusion of the parts, the suture may 
cut through the weakened tissues. The direction in which the sutures 
are passed is a matter of some importance. The needle should be car- 
ried through the tissues in a direction toward the operator, and brought 
out at the centre of the tear ; it is then re-entered and carried upward 

Fig. 371. 




Same as Fig. 367, with internal sutures 
passed, ready to tie. 




Emmet's needle for suturing the pelvic floor 



in a direction away from the operator to the point of exit, which should 
correspond with that of entrance. In this way the approximation will 
be much better than if the sutures are passed in a plane at right angles 
to the surface. The part of the suture seen in the floor of the wound 
lies 1 or 2 cm. nearer the perineal angle of the wound than the lateral 
points of entrance and exit. (Figs. 370, 372, 373, 374.) Immediately 
a suture has been introduced, it should be tied ; or the ends may be 
clamped till all have been laid. 

Near the vaginal outlet, the tissues being the least yielding just 
where the sutures enter the lateral wall, the part of the suture lying in 
the bottom of the wound is pulled upward. This is what we mean by 
a "lifting suture;" for it, silkworm-gut softened in sterilized water is 
the best material, being more elastic and smoother than either silk or 
silver wire, and less painful than the latter. On account of its elasticity 
it forms a symmetrical loop in the tissue, so that when the ends are 



REPAIR OF VAGINAL AND VULVAR LACERATIONS. 



635 



brought together the constriction, which is often produced by the sharp 
angular loop made by silver wire, is avoided. Silkworm-gut, owing to 
its smoothness and non-absorbent quality, is not irritating, and sutures 
of this material may be left with safety in the vagina for several weeks. 
To insure success in this operation we must bring about the approxi- 
mation of the torn structures within the vagina, and not only those on 
the skin surface. Two or three sutures introduced as described, with 
the belly of the sutures below the line of entrance and exit, will lift up 
a large tear, and approximate extensive raw surfaces and bring the 
torn edges of the fascia together in a most satisfactory manner. One or 
two superficial or half-deep sutures of fine silk on the skin surface will 
then complete the approximation. If, instead of adopting the method 
just outlined, all the sutures be passed from the skin surface in what 



Fig. 372. 



Fig. 373. 




Internal stitches in position. 



Internal stitches tied. 



would at first sight appear to be the natural curve beneath the lacerated 
tissue, it is only too probable that the really important part of the tear 
— viz., that within the vagina — will be left ununited. In this way a 
pocket is formed in the vaginal wall, in which secretions may collect, so 
that any attempt at union will be frustrated, and a troublesome perineo- 
vaginal fistula may even occur. In any case, although there may be 
good external union and the skin perineum be perfect, a relaxed outlet 
will surely be left. 

After-treatment. After the patient has been put to bed it will 
seldom be necessary to bind her legs together or make her keep strictly 
in the dorsal position. She may be allowed to turn slowly in bed, or 
even to elevate the knees, provided only that she keeps them together. 



636 



OBSTETRIC SURGERY. 



on 



Catheterization may be necessary al intervals for the firsl day or two 
account of ischuria or retention, but the patient should always be en- 
couraged to pass her urine voluntarily 
ii* possible. The bowels Bhould be 



Fig. 874, 




moved, after twenty-four hours, with 
citrate of magnesium or Rochelle sail 
given by the mouth, [f there be any 
straining at stool, the index finger 
should be anointed and introduced into 
the rectum for the purpose of removing 
any scybalous masses thai may be 
present. Alter the urine has been 
passed the labia should be separated 
and 2 grams (38s) of iodoform and boric 
aeid powder (1 :7) maybe dusted upon 
the wound. A pad of absorbenl cot- 
ton is then applied, and held in place 
by a T-bandage. The sutures may be 
removed in from eight to ten days after 
the operation. The patient should be 
kept in bed from twelve to fourteen 
days, and should not be allowed to 
exert herself much for four or five 
weeks. 

3. Complete Tear. The third form 
of recent tear involving the rectum 
starts ^ at the fourchette and extends 
back in the median line of the peri- 
neum through the sphincter ani, and 

to a variable extent involves the recto-vaginal septum. (Figs. 375, 376.) 

It must be remembered that the external tear 

occurs in the median line, while the internal 

rupture is always lateral, occurring on one or 

both sides. The function of the external 

sphincter muscle, when its fibres have been N S\\ -^Ss^ j 

torn through, is lost, and as a result we may 

have incontinence of faeces and flatus. Yet 

such patients will often put off an operation 

for months or years, until their condition is 

unbearable. An immediate operation is ad- 
visable in these cases, since, if it is successful, 

the patient will be spared much discomfort 

and misery. She saves time and the greater 

annoyance and suffering incident to a second- 
ary operation. Again, immediately after labor 

there is less tension of the torn structures, 

owing to loss of muscle-tone. 
Method of Opeeating. The woman 

should be placed in the lithotomy position, 

as described above. The complex tear is first reduced to a simple 

one, by closing the rent in the bowel, which is a very important part 



Internal stitches tied ; external stitches in 
position. 



Fig. 375. 



V *£C7\ 



Sagittal section of posterior vagi- 
nal wall, perineum, and rectum. 
The area embraced by ou rep- 
resents an outside, more or less 
superficial tear. The area above 
in represents a tear more on the 
inside of the vagina, and the area 
outside of so includes the whole 
skin perineum and sphincter ani. 



REPAIR OF VAGINAL AND VULVAR LACERATIONS. 



637 



of the injury. (Fig. 377.) Beginning at the apex of the tear, a 
series of interrupted catgut or silk sutures is inserted. Buried catgut 
sutures may advantageously be employed for this purpose. The first 
suture is introduced on the rectal side of the rupture, and it penetrates 
the tissues of the septum deeply enough (5 mm.) to ensure a firm 
hold. One turn of the first knot and two of the second will make it 
hold securely. The remaining sutures are passed in a similar manner 
until the ruptured sphincter is reached. It is not unusual to find that 

Fig. 376. 




Complete tear, involving the recto- vaginal septum. 

on one or both sides the torn ends of the sphincter have retracted, 
leaving a pocket. It is of the utmost importance that this condition 
be rectified ; the ends of the muscle must be sought out carefullv and 
brought into accurate approximation. A tenaculum may be employed 
to draw out an end of the retracted muscle, which is then secured by 
means of one or two catgut sutures passed through it. The other end 
having been caught, the sutures are passed through it and pulled tight, 
tied, and buried. To relieve undue tension upon these approximation 
sutures it is advisable to employ one or two silkworm-gut sutures, which 
are made to enter and emerge in the muscle farther away from the torn 
ends and circle about 1^- centimeters above the angle of the tear up to 
the recto-vaginal septum. 

After eliminating the rectal complication, we have left a tear such as 
has been described, involving the fourchette and usually extending a 
short distance upward in the median line, or into one or both sulci of 
the vagina. This part of the wound is closed by deep interrupted lift- 



638 



OBSTETRIC SURGERY. 



ing Butures in the manner detailed when speaking of the second form 
of laceration. (Fig. 378.) After these sutures nave been tied, it is 
advisable to employ a few superficial silk sutures to complete the 



l'i.;. 877. 



Fig. 878. 





Complete tear ; closing the rent in the bowel. 






Deep interrupted lifting sutures in position. 



approximation. (Figs. 379, 380.) To have union throughout, perfect 
approximation is necessary, and it is essential that the sutures be prop- 



Fig. 379. 



Fig. 380. 





All sutures laid ; vaginal sutures tied. 



Internal and external sutures tied. 



erly laid. In very deep lacerations it is sometimes advisable to use tiers 
of sutures, the first suture consisting of a running catgut suture laid in 



REPAIR OF THE LACERATED CERVIX. 639 

a plane near the bottom of the wound, and the next at a slightly higher 
level. The last tier may consist of interrupted silkworm-gut sutures, 
which are tied on the vaginal surface. An operation such as has been 
described will generally restore the relaxed outlet almost to its normal 
condition, if the parturient period has been properly conducted, so that 
puerperal sepsis is prevented. The repair may be postponed, and in 
some cases this has to be done, but only by an early operation can the 
parts be restored to their primitive integrity. All secondary opera- 
tions are less efficacious. 

After-treatment. The after-treatment is to be conducted in ac- 
cordance with the general principles laid down elsewhere. The same 
rules as to the evacuation of the bladder and the bowels advised before 
and after other operations must be carefully carried out. Catheters can 
be sterilized by boiling for five minutes in a 1 per cent, soda solution. 
This procedure, however, is very deleterious to the ordinary rubber or 
gutta-percha catheter, and for this reason glass catheters are invalu- 
able. Though they are sometimes broken in the boiling, this is of 
no great moment, as they are cheap, and by their use greater safety is 
insured. 

In ordinary instances the nurse may be allowed to give the enema, 
but in cases of complete laceration the physician should take this duty 
upon himself. The index finger, smeared with vaseline, should be 
gently introduced into the rectum, in order to determine the exact 
direction of the canal ; with this as a guide the syringe is carefully 
inserted and the injection is given slowly. This caution is not super- 
fluous. More than once the point of the syringe has been thrust between 
the stitches passed through the perineum. One case is reported in which 
it was pushed through the coat of the bowel, and a laxative enema was 
forced into the pelvic cellular tissue. The patient died from the exten- 
sive sloughing which followed. 

Straining during the act of defalcation must be avoided, and hard 
masses of fseces in the rectum must be removed by the finger of the 
physician. In doing this, pressure should be made toward the sacrum. 
As a rule, a vaginal douche is unnecessary. If the discharge is foul, 
but the patient has no fever, one consisting of a saturated solution of 
boric acid or of a 2 per cent, solution of carbolic acid may be employed, 
and if this procedure is followed by no improvement, the uterine cav- 
ity should be carefully explored and, if necessary, curetted. 

A pad of absorbent cotton is applied loosely over the vulva ; it is at 
first changed every two or three hours, and later three times daily. 

All perineal cases must be kept in bed for two weeks ; on the eighth 
day the external sutures are removed. The silkworm-gut sutures should 
be pulled out so that the wound surfaces are drawn together, rather 
than apart. The internal sutures can be removed at the end of two or 
three weeks. 

IMMEDIATE REPAIR OF THE LACERATED CERVIX. 

The primary operation for this condition is only rarely indicated. It 
is impossible for labor to take place without more or less extensive rupt- 
ure of the cervical tissues, but even in cases of severe laceration, it 



640 OBSTETRIC SURGERY. 

has generally been thought better, as a rule, to remedy any defect later, 
rather than add to the severe trials of the woman at the time of 
labor by immediate operation. In Instances of persistent hemorrhage 
from the circular artery, however, it may be necessary for the safety 

of the patient to repair the lacerated struct lire- at once in order to stop 

the bleeding, and not a lew cases are quoted in which life has apparently 
been saved by resort to this procedure. The most recent literature 
upon the subject shows an increasing tendency to undertake the immedi- 
ate operation in Less severe cases also, and when we consider the later 

dangers of a lacerated cervix (o the patient and the natural repugn- 
ance that exists in many cases to the secondary operation, together with 
the serious consequences resulting from the neglected cervical injuries, 
the question arises whether it is not better to unite at once the raw 
surfaces and thus effect two purposes at onee : (l)the closing of avenues 
by which infective material may enter, and (2) the avoidance of inju- 
rious results which may follow from the neglect to rectify the condition 
later. It is true that the tumefaction of the tissues may make it diffi- 
cult to secure proper coaptation, but with a little care any objection to 
the procedure on this score may be overcome. 

Method of Operating. The operation itself is comparatively 
simple. With the patient in the lithotomy position, the cervix is drawn 
down and held in position by means of a tenaculum or a volsella, and 
stitches are of about one inch apart from above downward. As care- 
ful approximation as possible should be obtained, a result which may be 
promoted, if necessary, by a few superficial stitches. A teaspoonful of 
iodoform and boric acid powder (1:7) may be dusted over the wound. 
The stitches may be removed about the twenty-first day. 



CHAPTER XXX. 

THE INDUCTION OF ABOETION AND OF PKEMATURE LABOR. 

Definition. Before dealing with the various means at our disposal for 
the artificial emptying of the uterus before term, it is necessary to dis- 
cuss briefly the significance of some of the numerous terms which have 
been applied to the interruption of pregnancy. Zweifel distinguishes 
two main classes of cases : (1) those in which the ovum is usually dis- 
charged in toto, and (2) those in which the fetus is extruded after rupt- 
ure of the membranes. Thus, he would apply the term abortion to 
expulsion of the ovum before the end of the sixteenth week, and that 
of premature labor to its expulsion between the beginning of the seven- 
teenth week and full term. Although much can be said from an 
anatomical standpoint in favor of this classification, the fact remains 
that when operative interference is indicated the question whether we 
are dealing with a viable or a non-viable child is often of predomi- 
nating importance as regards the selection of the method to be em- 
ployed. For our present purpose, therefore, it will be more convenient 
to adopt a different division, and to consider abortion as a delivery of 
the fetus before it is viable — i e., before the end of the twenty-eighth 
week ; while the discharge of the uterine contents between this time 
and full term will be spoken of as premature labor. 

Mention has already been made in another chapter of cases in which the 
exciting cause of abortion or of premature labor has been beyond our 
reach ; but a very important class still remains, namely, those instances 
in which the physician himself, for good cause, finds it necessary to 
bring about the premature discharge of the contents of the pregnant 
uterus. 

The induction of abortion or of premature labor in non-pathological 
conditions is rightly regarded in civilized communities as a moral and 
civil crime, and one to be punished with severe legal penalties. 
Although, therefore, it is generally agreed that medical science may on 
rare occasions be above the law, it is evident that it must always be the 
first duty of the physician to place both his patient and himself beyond 
the imputation of any intention to commit a serious crime. There 
should be no false modesty or concealment about the operation. Inten- 
tional secrecy may, unjustly, be looked upon as prima facie evidence 
of criminality. When, however, the mother is in such physical con- 
dition that further continuance of gestation would be perilous to her 
life, it is generally conceded that interference with pregnancy is not 
only justifiable, but a solemn duty. But so serious a course should 
never be decided upon by one physician alone. To demonstrate abso- 
lutely the absence of criminal intent should be his first thought. This 
end may be best accomplished by calling in consultation a colleague, 

41 ( 641 ) 



6 12 OBSTETRIC SURGERY. 

and not proceeding to operation until the oecessity for it has been care- 
fully demonstrated, a full explanation of the circumstances of the case 
has been made to the members of the family more directly concerned! 
and the course to be pursued has met with their full approval. 

The first poinl t<> be considered in deciding whether an interference 
with gestation is necessary is the physical and mental condition oi* the 
mother. Should it seem to the physician, after careful thought and 
consideration <»f the particular case, that the woman'.- life will be 
seriously threatened by allowing the pregnancy to continue to term, the 
next question to he decided is, whether it may not be possible to wait 
until there will exist some chance for saving the life of the infant as 
well ; in other words, whether we ought to bring about an abortion or 
a premature labor. 

Indications. Among the conditions in which interference with gesta- 
tion may be justifiable are the following : 

1. Death of the foetus in utero. 

2. Grave pathological conditions of the viscera, such as advanced 
cardiac disease, phthisis which is clearly making rapid progress on 
account of the pregnant condition, kidney lesions threatening eclampsia, 
and persistent and advancing jaundice. An acute nephritis is especially 
dangerous when it occurs during pregnancy, and experience has shown 
that the emptying of the uterus has often cut short the process. 

3. In the vomiting of pregnancy which has resisted all other 
measures, and where the patient's strength is rapidly failing, the induc- 
tion of abortion may be necessary as a last resort. Still, it is only 
right to wait as long as we dare, and sometimes to give the stomach 
long intervals of entire rest, the strength of the patient being partially 
supported meanwhile by nutrient enemata. The various surgical pro- 
cedures which have been tried are very rarely of any use in these cases. 
Occasionally applications to the cervix have appeared to be beneficial, 
and Martin states that dilatation in his hands has been successful ; yet 
Runge holds that this method is absolutely unreliable. 

4. Certain diseases of the blood and of the nervous system — e. g., 
pernicious anaemia, leucocythsemia, acute melancholia, acute mania, and 
inflammatory affections of the brain — apparently depending upon the 
pregnancy or increased by it. In pernicious anaemia Bischoff prefers the 
induction of premature labor, and denies that abortion is necessary ; he 
argues that anaemia becomes dangerous only during the latter half of 
pregnancy. 

5. Where the mechanical conditions are such that the birth of a 
viable child becomes an impossibility ; for example, in cases of retro- 
flexion of the gravid uterus with incarceration below the superior strait, 
or an abnormally small calibre of the vagina such as would prevent the 
passage of the child. Again, the presence of benign or malignant 
tumors which would effectually preclude delivery of a child at term 
through the natural passages, and hernia of the uterus resisting all 
other treatment bring up the question of the advisability of putting an 
end to the pregnancy. 

When the uterus is retroflexed and incarcerated, and when all at- 
tempts, even under narcosis, to raise it above the superior strait have 
proved ineffectual, the indication for abortion is absolute. Except in 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 643 

these cases, however, it is always the duty of the attending physician 
to weigh carefully the question how long it may be safe to delay empty- 
ing the uterus ; and if it be possible, without grave risk to the mother, 
to wait until there is a chance of securing a living child, interference 
in the later stages of pregnancy should be preferred. Under some cir- 
cumstances in cases of narrowing of the vagina, where the smallness 
of the calibre is due to cicatrices, lateral incisions or other operations 
may be indicated. In cases of obstruction, from whatever cause they 
may arise, the question of Cesarean section with its various modifica- 
tions should always be taken into consideration. 

Methods of Inducing Abortion. 

The mechanism of the premature discharge of the contents of the 
pregnant uterus resembles in the main that of normal labor. In bring- 
ing about the expulsion by artificial methods we should, as far as pos- 
sible, imitate nature, the essential element in the operation being to 
secure contractions of the uterus and the consequent evacuation of the 
organ. The process is really a reflex act, implying the application of a 
stimulus and a conveyance of it to nerve-centers, from which an impulse 
is sent down to the peripheral nerves which causes the uterus to contract. 

Such a reflex act may be brought about in various ways, and the seat 
of the original stimulus need not of necessity be the uterus itself. It 
has long been known that irritation applied to the breasts, and more 
especially to the nipples, is often followed by uterine contractions of 
greater or less intensity. This fact has been taken advantage of by 
Scanzoni, who has formulated a method of inducing abortion by irrita- 
tion of the nipples. But, as might be expected, the strongest and most 
effectual contractions can be brought about by the application of the 
stimulus directly to the interior of the uterus. 

Stimuli may be distinguished as (1) chemical, (2) mechanical, (3) 
thermic, (4) electrical. An accurate classification along these lines, 
however, presents great difficulties, since some stimuli may act in more 
than one way. For instance, drugs may have a chemical and a 
mechanical effect and hot water injections may act as a mechanical as 
well as a thermic stimulus. For practical purposes stimuli may be 
conveniently discussed in three main classes : (1) Drug stimuli. (2) 
Stimuli applied to some region other than the interior of the cervical 
canal or the uterine cavity. (3) Stimuli applied directly to the interior 
(a) of the uterine cavity or (b) of the cervical canal. 

1. Drugs. Many drugs have been employed for the purpose. 
Among the chief of these so-called ecbolics are ergot, cotton-root-bark, 
quinine, pilocarpine, the smut of Indian corn (ustilago maidis), and 
various essential oils, especially those of savine, rue, parsley, tansy, 
and pennyroyal. Of all these the most effective is undoubtedly ergot, 
which is capable of bringing on, as well as of strengthening, uterine 
contractions. But the contractions excited by ergot have a tonic char- 
acter in contradistinction to the normal clonic or recurrent contractions 
which it should be our aim to secure. Thus, even when given in quite 
large doses, it often fails to accomplish fully the object in view, and 
operative interference may become necessary to complete the evacuation 



644 



OBSTETRIC SURGERY. 



of the uterus. Of the other drugs of this class, it may be said that 
their action is even i v uncertain than that of ergot, and the exhi- 
bition of them in doses sufficient to cause abortion is always accompanied 
by considerable risk and even danger to the life of the patient. Oil of 
tansy and oil of rue arc much relied on by the laity for the production of 
abortion, and almost every day one may read <>f fetal results attending 
their use. Oil of tansy in large doses is .-aid to excite epileptiform 
convulsions; quite recently one of my colleagues met with Mich a case 
in his practice. 

Abortion has been brought about by reflex stimulation of the 
uterus through free purgation. Magnesium sulphate in heroic doses 
has not infrequently been used for this purpose. Its action, however, 
is quite uncertain, and nothing can be said in favor of this method. It 



Fig. 381. 




Field of operation and the neighboring parts protected by gauze diaphragm, towel and stockings. 



is probable that the irritant purgatives have much more effect, but their 
use in sufficient doses is highly dangerous. It is more than possible 
that oil of tansy and oil of rue act in this way. In brief, it may be 
said that the employment of drugs for bringing about the evacuation of 
the uterus should be entirely discarded. Their action is uncertain and 
slow, and in effective doses their use is always accompanied with 
danger. 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 645 

2. Scanzoni's method, which consists in massage or rubbing of the 
nipples, is uncertain in its action and sometimes exceedingly painful to 
the patient. It is not to be recommended. 

Tamponade of the vagina is very effective in some cases, and, as has 
been said, is often employed in cases of inevitable abortion to stop the 
hemorrhage and to bring about dilatation of the cervix and contractions 
of the uterus. The tampons may be made of gauze or cotton, or the 
colpeurynter more especially recommended by C. Braun may be em- 
ployed. The external parts having been carefully disinfected, the 
vagina is first rendered as aseptic as possible by flushing with several 
douches ; it is then washed with soap and water, a cotton sponge being 
used, and afterward with a 2 per cent, solution of creolin, followed by 
a 1 : 1000 solution of mercuric chloride. After having been finally 
irrigated with an abundance of normal salt solution, it is dried with 
small pledgets of aseptic absorbent cotton. In the further steps of the 
procedure it is advisable to employ a sterilized gauze perineal apron, 
the operator working through a slit in it which corresponds to the 
vulvar opening. Two or three tampons of sterile absorbent cotton, or 
of 10 per cent, iodoformized or plain sterile gauze, are then introduced 
on either side of the cervix, and are held in position for several minutes, 
moderate pressure being employed. After this a fresh tampon is in- 
troduced, which is followed by others until the vagina is completely 
filled. (Fig. 381.) Dry tampons stay in place much better than 
those which have been soaked in disinfectant solutions, and are quite as 
efficient. In the place of these tampons the colpeurynter may be 
employed. (Fig. 382.) The tampons or colpeurynter should not be 
allowed to remain in position more than 
twenty-four hours. After their removal a FlG - 382 - 

2 per cent, solution of carbolic acid may ^imw^ 

be employed as a douche. In view of the 
fact that in susceptible patients poisoning 
has been sometimes produced by carbolic 
acid, many authorities prefer to use sterile 
normal salt solution. If the first tam- 
ponade does not produce the desired effect, 
a second or even a third may be employed.. Colpeurynter. 

The method is usually effective, but it has 

the disadvantage that it is almost always slow and not infrequently 
painful. 

Kiwisch's method consists in the injection of warm water against the 
cervix. He recommends the use of a fountain syringe and water at a 
temperature of about 42.5° C (106° F.). The douche is given two or 
three times daily for fifteen minutes at a time, the stream being directed 
against the cervix. Care must be taken not to inject air into the 
cervical canal. The heat of the water and the force of the stream are 
important factors in this method, which, although slow, is often effective. 

Electricity. The use of the galvanic current has been strongly rec- 
ommended by some authors. The positive pole is applied over the 
sacral region or over the lumbar vertebra?, and the negative pole is 
applied to the exterior of the cervix in the posterior cul-de-sac. The 
method has not, as yet, been much employed. 




646 OBSTETRIC SURGERY. 

3. [a) Krauaefs method consists in introducing a flexible elastic 
bougie between the wall of the uterus and the membranes. The proced- 
ure bas beeu modified in various ways. Some authorities allow the 

instrument to remain in place from twelve to twenty-four hours, while 
other- hold that it should be introduced and then immediately with- 
drawn. Bougies are preferable to catheters, since in the employment 
of the latter there is danger of introducing air into the uterine sinuses. 
The instrument must he soft and flexible, otherwise there is great risk 
of perforating the amniotic; sac, or even the uterine wall itself. Steel 
sounds should not be employed. Strict asepsis of the external genitals 
and vagina and of the hands of the operator and his assistants is to be 

observed. 

The procedure may be carried out as follows: The cervix being 
thoroughly exposed, the bougie is pushed gently in until the tip lies 
near the fundus. After being allowed to remain for several minutes it 
is withdrawn, and the vaginal canal is packed with tampons ; or the 
bougie may be left in situ and the tamponade of gauze be made around 
it. Should there be much hemorrhage, evidenced by blood flowing 
down along the bougie, so that we have reason to suspect that the placen- 
tal site has been invaded, the bougie should be withdrawn and reinserted 
in another direction. The hemorrhage will then probably cease spon- 
taneously. If, however, it becomes alarming, a firm vaginal tamponade 
may be made, or preferably a colpeurynter may be inserted into the 
vagina close up to the cervix and allowed to remain for some hours, 
unless indications for its removal should appear. This method is not 
to be recommended during the first two or three months, but in the 
later stages of pregnancy it is one of the most satisfactory which we 
possess. It usually acts promptly and effectively. The operation in a 
crude form is often resorted to by women in order to free themselves 
from the consequences of pregnancy, frequently w T ith disastrous re- 
sults, which are due almost always to infection following a total lack 
of asepsis. It is also in vogue among the unsavory class of men and 
women known in communities as " abortionists." 

Hamilton's method consists in the circular detachment by means of 
the finger of the foetal membranes for a short distance above the internal 
os. The employment of this method presupposes a dilatation of the 
cervical canal so that it is capable of admitting a finger. Its action is 
similar to that of Tarnier's method, but is not so certain. 

Tarnier's method consists in the insertion of a dilatable rubber bag 
into the cervical canal and extending slightly above the internal os. 
The distention of this bag with w T ater, and the subsequent separation of 
the membranes from the decidua for a certain distance above the inter- 
nal os, excite uterine contractions, with a coincident dilatation of the 
cervix. Except that in Tarnier's method the bag is inserted somewhat 
higher up, the procedure differs in no essential respect from that of Barnes. 

The advantages of' this method consist in the preservation of the bag 
of waters, and in the simultaneous induction of uterine contractions 
and of dilatation of the cervix. 

In using any of these rubber bags it is necessary that the material 
be new and be w r ell preserved, otherwise they will be very apt to rupt- 
ure when distended and thus allow a quantity of w r ater to get into the 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 647 

uterus. They should be rendered thoroughly aseptic, both inside and 
outside, before being employed, and the water used for filling them 

Fig. 383. 




Barnes' bag. 



should previously have been boiled, so that if rupture takes place no 
great harm may be done. This method usually acts quickly and 



Fig. 384. 




Tarnier's uterine dilator. 



thoroughly, and is especially to be recommended in pregnancies be- 
tween the third and the end of the sixth month. (Figs. 383, 384 ; 
and 385.) 



Fig. 385. 




Tarnier's uterine dilator in situ : the bag is round in shape, but is compressed by the intra- 
uterine tension. 

Cohen's method consists in the injection of fluids between the mem- 



6 is OBSTETRIC SUBQEBT. 

branes and the uterine wall. No special apparatus is necessary, since 
one which will serve all purposes can readily be Improvised. 'The 
nozzle of the syringe or douche bag should be from \ to ] inch, 0.31- 
0.62 cm., in diameter, and from 6 to * inches, L5-20 cm., in length. 
It is better to employ a sterilized piston-syringe, which will admit of 

the injection being made more gradually. The nozzle should he intro- 
duced carefully and the fluid injected -lowly, BO that rupture of the 
membrane may he avoided. From 1 to 3 ounces, ;>()-<)() cc., of the 
sterile solution will probably be sufficient. The apex of the nozzle 

should he passed about two inches, 5 em., up the cervix beyond the 
external os. The distance will, of course, vary according to the dura- 
tion of pregnancy and consequent size of the uterus. All air must be 
expelled from the apparatus before the insertion of the nozzle. Should 
the desired effect not follow in the course of six hours, the injection may 
be repeated. The method is not to be recom mended. Septic infection 
has often been observed, much more frequently than after employment 
of the majority of the other methods. Cases of thrombosis and embo- 
lism have also been reported, possibly due to the injection of air into the 
uterine sinuses. The advantages offered by it are that it is not only 
prompt in its action, but also very certain. 

SoheeVs method, with its modifications, depends upon the drawing off 
of the amniotic fluid, thus causing a more or less extensive separation 
of the membranes from the decidua and rendering the ovum a foreign 
body, which must naturally excite uterine contractions. The point 
selected for penetration or rupture of the membranes may be at the 
internal os, or higher up, so that a valvular opening is obtained. It is 
advisable to prevent, as far as possible, the entrance of air into the 
cavity of the amnion, since it is impossible to say how long it may take 
before the pains set in and the process terminates. Sometimes labor- 
pains come on in two or three hours, but at other times their appaar- 
ance may be delayed for as many days. In the latter case there is 
danger that septic infection may follow the admission of air. Scheel's 
is probably the most certain of the methods employed for the induction 
of labor, but it possesses several disadvantages, not the least of which, is 
that in almost every case its employment is followed by a dry labor, if 
the membranes are punctured at the internal os. The fact that the 
amniotic fluid has escaped, and thus left a solid mass, the fcetal body 
and membranes, to be expelled by the uterus, renders the dilatation of 
the cervix a slower and more painful process. The contractions of the 
uterus are to a great extent ineffective, the lav T s of hydrostatics no 
longer applying, since the uterus now contains solid and not fluid con- 
tents. Again, it has been found that not infrequently portions of the 
membranes are left in the uterus. The former of these objections can 
be overcome by adopting the modifications suggested and carried out by 
Hopkins and Meissner. They make the puncture some distance above 
the internal os, so that enough of the amniotic fluid drains away to 
bring on uterine contractions, while sufficient still remains behind to be 
of value in dilating the cervical canal for the after-coming parts of the 
ovum. In advanced pregnancy it is best to allow the water to drain 
off slowly. Various kinds of instruments, from a simple pin or finger- 
nail to a complicated aspirating-needle, may be made use of. 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 649 

(b) Dilatation of the Cervical Canal. This may be accomplished 
in many ways. It may be called for as the introductory step in car- 
rying out other methods — e. g., Hamilton's — where it is necessary 
to gain entrance for the linger to the uterine cavity. The cervix may 
be dilated, if it is soft enough, by means of the finger, by Barnes' bag, 
or by metal or hard-rubber dilators. Dilatation by means of the 
Barnes' bag is effective and comparatively safe and speedy. It is more 
applicable to the induction of premature labor than of abortion. Dig- 
ital dilatation is in early cases a difficult procedure. Moderate dilata- 
tion with easily sterilized metal or hard-rubber dilators is generally to 
be preferred. (Fig. 386.) Though not always effective, it succeeds in 

Fig. 386. 




Hegar's dilator. 

the majority of cases, and has the advantage of being one of the safest 
methods known. 

When the patient presents herself in the first two or three months, 
and the necessity for putting a stop to the pregnancy is absolute, the 
swiftest and surest method in the hands of a skilled operator is by 
means of dilating and curetting. The procedure resembles somewhat 
that pursued in gynecological cases. The cervix is dilated with a steel 
branched dilator to a half or a full inch. The ovum is then separated, 
if possible, with a dull curette, and the whole is withdrawn with uterine 
dressing-forceps. The cavity is then gone over carefully with a sharp 
curette. Frequently the ovum has to be brought away piecemeal. The 
whole operation can be done in from ten to twenty minutes. It is 
absolutely sure, and with proper precautions should never be dangerous. 

Methods of Inducing Premature Labor. 

For this purpose it is possible to use any of the methods which have 
been spoken of in dealing with the induction of abortion. But, as has 
already been said, in this connection, a new factor is encountered, namely, 
the possibility of obtaining a viable child, while at the same time the 
mother is relieved of a dangerous encumbrance. Whereas in the former 
case the foetus may be regarded as a foreign body, to be gotten rid of 
by the means most conducive to the welfare of the mother, it now pre- 
sents itself as a living being, whose life may be put nearly on a par 
with her own. In choosing methods, then, we are restricted to those 
which will give the infant the best chance of life consistent with the 
safety of the mother. For this reason methods such as that of Scheel, 
which depend upon the withdrawal of the liquor amnii, are not advis- 



660 OBSTETRIC 8UBQERT. 

able. Since their use entails a "dry labor/' they increase to some 
exteni the risks to the child. It will perhaps be more convenient to 
state, first, the procedure at present adopted by most of the prominent 
obstetricians In this country, and then to speak briefly of the advant- 
ages and disadvantages of the other methods. 

Operation. The cervix Is dilated gradually to one inch with a steel 
branched dilator. The membranes are then peeled np from the lower 
Uterine Segment with a uterine sound or with the finger. This step has 
been recommended by Jewett, and in the hand- of a skilful operator 
it would seem to facilitate matter.- a good deal. One or two bougies 
(English No. 10 or 12) are then passed between the uterus and the 
membranes. The proximal end of the bougie having been cut oil' and 
a stylet introduced, the bougie is passed np as far as it will go, the 
lower end, if any remains outside, being seized with a Keith's forceps 
and carried into the uterus bit by bit. The cervix is then packed with 
iodoform-gauze. Instead of the bougies and gauze, one of the bags 
recommended respectively by Champetier de Ribes, McLean, and 
Barnes, may be used. Labor is usually completed in from twenty- 
four to thirty-six hours. In urgent cases the dilatation may be com- 
pleted with the hands, or, after the os internum is obliterated, by means 
of water-bags. In extreme emergencies Diihrssen's incisions may be 
employed after the os internum is effaced. But, contrary to the practice 
of this author, the incisions should be sutured immediately after labor. 

With respect to the other methods, it may be said that the use of 
drugs is most emphatically to be condemned. Scanzoni's method is 
uncertain and painful, and possesses only historical interest. Tampon- 
ade of the vagina is a fairly reliable and a safe method. In placenta 
prsevia the colpeurynter is to be preferred. Both these and Kiwisch's 
method are slow 7 in their action, but they offer the advantage of pre- 
serving the membranes unruptured. Krause's method is one of the 
best which we possess, more especially if care be taken not to puncture 
the membranes. Hamilton's method and Tarnier's method are reliable, 
and are comparatively easy to carry out. Cohen's method is equally 
certain, but it is not so simple a procedure, and is objectionable on 
account of the danger of the injection of air into the uterine sinuses. 
Scheel's method and its modifications have the disadvantages attaching 
to a dry labor, but when the foetus is dead and the case is not urgent it 
is one of the best at our disposal. It is often slow in its provocation 
of uterine contractions, but when these have been once established 
delivery as a rule is speedy. Although many living and viable children 
have been born in cases in which it has been employed, when the 
chances for the child's life are weighed the method must be considered 
inferior to those in which the amniotic membranes are left intact. The 
employment of tents, apparently even under the most aseptic precau- 
tions, for dilatation of the cervical canal has often been followed by 
infection. Tarnier's procedure is better, and is not difficult to carry 
out. Digital dilatation is comparatively simple, and, although some- 
times slow r , has been effected in an hour or two by many operators. In 
general, therefore, it may be said that in urgent cases — e. g., in eclamp- 
sia — where it is necessary* to empty the uterus as quickly as possible, 
the method first described, or some modification of Tarnier's procedure, 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 651 

is to be preferred. In cases of placenta prsevia with severe hemorrhage 
the colpeurynter is highly efficacious. When the case is less pressing 
it is always advisable to be content with gradual dilatation, and to 
leave the bag of waters unruptured till later. All other things being 
equal, the method should be chosen in which the individual operator 
has the most experience. The procedure of Krause and Tarnier and 
the employment of the colpeurynter are all applicable. 

After the expulsion of the ovum in abortion or premature labor the 
membranes and placenta should be minutely examined, and we should 
make sure that the uterus has been completely emptied. If this has 
been done, and if all the necessary manipulations have been carried out 
with strict aseptic precautions, a normal puerperium may be expected. 
The management of such cases is similar to that after spontaneous 
labor. 

i 
Retained and Adhered Placenta. 

It occasionally happens that the birth of the foetus is followed almost 
immediately by the delivery of the placenta. But, as a rule, from ten 
to thirty minutes may be devoted to the necessary care of the mother 
and child, while the expulsion of the placenta is awaited. During this 
time the uterus should carefully be watched, the hand of the nurse or 
doctor being kept on the abdomen to control the fundus. 

Retained Placenta. Not infrequently the uterine contractions, to- 
gether with the pressure exerted by the abdominal muscles, fail to 
cause the delivery of the placenta, which in such cases is usually found 
resting in the uterus. To such a condition the term retained placenta 
is applied. 

Adherent Placenta. More rarely the placenta is not only retained in 
uter o, but it remains fastened to the uterine wall. To this condition the 
term adherent placenta is applied. Of necessity, an adherent placenta 
must also be a retained placenta, but since the converse is by no means 
true, for the sake of simplicity, in describing the methods of dealing with 
such cases, it is more convenient to keep the two conditions distinct. 

Mechanism of Placental Separation. To obtain a clear idea of the 
subject it is necessary to understand the mechanism which brings 
about the natural detachment of the placenta from the uterine walls. 
The chief factor is the expulsive force of the uterine contractions. As 
the uterus becomes smaller the area of the placental site is lessening, 
tending to separate the placenta from its attachment. The expulsion 
of the placenta may take place in either of two ways. The first few 
contractions of the uterus after the completion of the second stage may 
be sufficient to loosen the placenta entirely, and to expel it folded length- 
wise of the uterus in a more or less fusiform shape. They may not, 
however, detach the whole placenta, but only its central portion. The 
marginal attachment may still remain, blood collecting in the cavity 
formed between the central portion of the placenta and the uterine wall. 
The blood-accumulation, together with further contractions of the uterus, 
then forces the placenta down through the opening in the membranes, 
so that it emerges by its amniotic surface from the outlet, dragging the 
membranes after it. In either case, normally all the placenta, together 



652 OBSTETRIC SURGERY. 

with the membranes and the superficial layer of the decidua, should be 
expelled. 

Causes of Retention of the Placenta. The placenta may be retained in 
the uterus by reason of feeble contractions, or, in other words, from 
inertia uteri. A full bladder, a rectum packed with fasces, or :i pelvic 
tumor may act reflexly to prevent the efficient action of the expulsive 
forces. Sometimes, though wholly expelled from the uterine cavity, it 
may -till be retained in the roomy vagina] vault. 

Causes of Adherent Placenta. One of the most frequent factors lead- 
ing to adhesion of the placenta to the uterine wall is syphilis. A non- 
specific placentitis is a very rare condition, and when present it may lead 
to adherent placenta. A chronic endometritis is sometimes responsible 
lor this complication. 

Treatment of the Retained Placenta. It is a cardinal rule, as a pre- 
caution against infection, to allow nothing, whether finger or instrument, 
to enter the uterus or vagina after labor, if possible to avoid it. The 
risk to the patient, even in these days of asep>is, is greatly increased by 
manipulations within the passages at this period. Should the expulsion 
of the placenta be delayed beyond half an hour, it is well to try, first, 
the effect of emptying the bladder. It not infrequently happens that, 
although it may have been carefully emptied before, the bladder becomes 
distended during the progress of the second stage of labor, and its evac- 
uation may succeed in evoking vigorous uterine contractions and the 
prompt expulsion of the placenta. 

If it be quite certain that the bladder and rectum are empty, Crede's 
method of expulsion should be tried. Traction upon the cord is not 
permissible. When the placenta is not yet detached from the uterus, 
pulling upon the cord may cause a partial separation, with alarming 
hemorrhage. Eough traction may even result in complete inversion 
of the uterus. If the use of Crede's method does not prove successful 
at the first attempt, it may be employed repeatedly and patiently at / 
intervals, but no violence should be used. As the placenta is being 
delivered, the membranes should be gently twisted into a cord and the 
whole slowly withdrawn. This procedure facilitates their removal and 
tends to prevent leaving behind fragments that may favor hemorrhage 
or infection. If expulsion be not effected by expression after a thor- 
ough trial, it will be necessary to institute a careful examination, in 
order that the cause of the retention may be determined. Should the 
placenta be found lying in the upper part of the vagina, it can be. gently 
withdrawn by means of one or two fingers pushed up past it and then 
hooked over its upper margin. The extraction may be assisted by press- 
ure from above through the abdominal wall. • 

Treatment of Adherent Placenta. When an examination shows that 
the placenta still remains in the uterine cavity notwithstanding the manip- 
ulations that have been described, we may reasonably suspect adherent 
placenta, and should take steps at once for bringing it away. In pre- 
antiseptic days the expectant treatment may have been allowable in 
view of the fact that the removal of the adherent placenta was considered, 
and justly so, a dangerous operation, the mortality being from 7 to 9 
per cent, of cases so treated. The patient and persistent use of Crede's 
method may bring about the separation and expulsion of a moderately 



INDUCTION OF ABORTION AND- OF PREMATURE LABOR. 653 

adherent placenta. Where this has not succeeded after one or two hours, 
or earlier if hemorrhage is occurring, we must proceed to extraction. 
Chloroform or ether should be administered to light secondary an- 
aesthesia, and the outer genitals of the woman and the hands and arms 
of the surgeon should be rendered as nearly as possible sterile. The 
cord is taken in the left hand and gentle traction is made till the slack 
is taken in ; the right hand and forearm are inserted into the vagina, 
the fingers following up the umbilical cord as a guide to its insertion. 
The so-called hourglass contraction, formerly so much spoken of as inter- 

FlG. 387. 




Manual extraction of placenta from lower uterine segment. (After Ribement Dessaignes 

and Lepage.) 



fering with the manual extraction of the placenta, is caused by the 
meeting of the dilated or easily dilatable lower uterine segment with 
the more firmly contracted and less dilatable upper segment at the 
retraction-ring. Should there be trouble at first in entering the uterus, 
either at the cervix or at the site of the retraction-ring, it can generally 
be overcome by the patient application of gentle pressure. The edge 
of the placenta having been found, the fingers are gradually worked 
under it, and sweeping movements are made until the adhesions are 
broken up. The procedure may sometimes be facilitated by inserting 



654 



OBSTETRIC SURGERY. 



two fingers held widely apart between the placental surface and the 
uterine wall, and then bringing them together like the blades of a pair 
of scissors, In the meantime oounterpressure should be made through 
the abdominal walls upon the fundus, cither with the operator's lefl 
hand or hv an assistant. It must be insisted again that all attempts 

at extraction by pulling on the Cord be avoided. After all the adhe- 
sions have been broken up, the margin of the placenta is carefully 

can-lit by a finger, and the whole mass lying on the palm of the hand 
can he forced out of the uterus. A careful examination of the mem- 



FlG. 388. 




Artificial removal of adherent placenta. (Modified from Ribement Dessaignes and Lepage.) 

branes and of the placenta should then be made by an assistant, to learn 
if fragments have been left behind. It is better that, before removing 
his hands from the uterus, the operator make sure that the evaeuation 
has been complete. Should fragments still remain in the uterus they 
should be at once removed by the hand, which may be supplemented, 
if need be, by the curette. These manipulations should be followed by 
an intra-uterine douche of normal salt solution, care being taken that 
no air is introduced. One or more full doses of ergot are usually 
advisable after the evacuation of the uterus has been completed. 



CHAPTER XXXI. 

THE FORCEPS. 

The obstetric forceps 1 is essentially a pair of steel hands for grasping 
the foetal head and extracting it from the birth-canal in certain cases of 
difficult labor in which the natural powers are inadequate to expel it. 

The invention, it is generally assumed, dates from the seventeenth 
century, and it is credited to Peter Chamberlen, an English obstetrician. 
It was for many years kept a secret by the Chamberlen family. The 
invention was sold to others under bond of secrecy, but finally became 
the property of the profession. The instrument of Chamberlen con- 
sisted of two arms with spoon-shaped blades to fit the foetal head. The 
arms crossed each other, articulating at the point of intersection. 

In 1723 Jean Palfyn, a professor of surgery at Ghent, presented to 
the Academy of Science at Paris an obstetric forceps with parallel arms 
articulating at the lower ends. He called it the iron hands. In both 
the Chamberlen and Palfyn instruments the cephalic ends were provided 
with a single curve only, and that on the fiat, in conformity with the 
shape of the head. Levret, in France, and Smellie, in England, at 
about the same time (1747 to 1752) introduced important improvements 
in the forceps, chief of which was a second curve, adapting it to the curva- 
ture of the pelvic axis. On their patterns the various models in use 
to-day are mainly based. 

The obstetric forceps, however, is an invention of much greater an- 
tiquity than is usually attributed to it. Crude patterns of forceps are 
known to have been in use several centuries before the Christian era. 

Description. The obstetric forceps consists of two interlocking crossed 
arms or branches. The arms are distinguished as left and right, the one 
passed on the left side of the pelvis being the left arm, and conversely. 
Each has four parts — handle, lock, shank, and blade. 

The handles when the arms are locked fall into position to be both con- 
veniently grasped by one hand of the operator. They are sometimes 
made smooth, but for a more secure hold are generally roughened or 
corrugated on their outer margins. A knob at the lower end adds to the 
security of the grasp. There is usually a transverse projection at the 
upper end of each handle over which a finger may be hooked when 
making traction. An adjustable screw or other device between the handles, 
to limit the compressive action of the blades, as provided in some forceps, 
is of doubtful utility. The regulation of the pressure upon the head during 
traction is a matter which is better left to the skill of the operator. The 
handles are best made of metal, or at least of material which will admit 
of sterilizing by heat. 

The lock in all models of forceps is based either on the Smellie or the 

1 The word " forceps " is a singular noun ; the use of the term as plural is a common error, and it is 
equally erroneous to speak of a pair of forceps when only one instrument is meant. 

(655) 



656 OBSTETRIC 8UBQERT. 

Levrel pattern. The former is constructed on the principle of a mortise 

and tenon; in the latter there IS on the left <>i lower half a thumbscrew, 

or a j>in Burmounted by a button, and in the edge of the other half a 

notch into which the pin or screw fits. It i> essential that the articula- 
tion he loose enough to permit locking easily, yet at the same time it 
should hold the arms securely in proper relation with each other. Obvi- 
ously the farther the lock from the handle, the greater will he the 1< ver- 
like action of the forceps in compressing the head. It ought to he bo 
located as to permit a sufficiently firm grasp of the head without undue 
pressure upon it. To this end it is usually placed about one-third way 
from the proximal to the distal extremity of the instrument. 

The shanks connect the handles and blades and are necessary to give 
the leugth required for high operations. 

The blades in the prevailing patterns of forceps have a double curve — 
a cephalic and a pelvic. The former adapts them to the shape of the 
foetal head, the latter to that of the birth-canal. 

The cephalic curve is essential to all midwifery forceps. It is some- 
what elliptical rather than circular, since the former better accommodates 
itself to heads of different sizes. The head curve in best models is from 
15 to 18 cm., 6 to 7 inches, in length. This gives room for the largest 
possible cephalic seizure. When the instrument is locked the greatest 
distance between the blades should be about 7.5 cm., 3 inches. With 
a smaller interval blades of proper length would be too nearly straight, 
and their hold upon the head insecure; with a greater width the maternal 
soft parts would be needlessly exposed to injury. 

The interval between the tips when the instrument is closed ought not 
to be less than 25 mm., 1 inch, otherwise the child's head is liable to be 
injured. 

It is desirable that the point of greatest divergence between the blades 
be not more than 7.5 cm., about 3 inches, from the tips, since the head 
is pressed toward the tips during traction and is exposed to injury when 
the interspace at the upper part of the blades is too narrow; moreover, 
rotation is interfered with. 

The pelvic curve of the blades should be such that when the closed 
instrument lies on its back, on a plane surface, the centre of the tips 
shall be about 8.8 cm., about 3J inches, above the plane. A greater 
curvature is better suited to high and a lesser one answers for low opera- 
tions. But for general use an average pelvic sweep is required. In the 
usual pattern the cephalic and the pelvic curves are nearly equal. A third 
or perineal curve, to be found in some obsolete patterns, is cumbrous and 
useless. 

Short, straight forceps, so called, about two-thirds the full length, and 
having no pelvic curve, was formerly in favor to some extent for lifting 
the head over the perineum, but is now seldom used. A single long 
double-curved forceps is sufficient for all purposes. 

In the approved models of forceps the blades are fenestrated. This 
not only conduces to lightness but more evenly distributes the pressure. 
The open blades, too, take up less room than the solid. The fenestra is 
usually from 9 to 13 cm., 3 J to 5 inches, in length, and is wide enough 
to leave a rim of 1 cm., f inch, in width. 

The instrument should be made of the best tempered steel. Some 



THE FORCEPS. 657 

degree of elasticity is desirable, yet there must be rigidity enough to 
hold the head securely. In order to this the weight should be so 
distributed that the shanks are strong and nearly unyielding and the 
blades light, especially toward the tips. Yet it is essential that the 
blades have sufficient thickness to permit rounding off all edges. This 
is particularly important at the tips and at the margins of the fenestra?. 
A common fault with forceps is too great sharpness of the edges of the 
blades, and injuries of the scalp are of frequent occurrence in consequence 
of this defect. 

The instrument should be kept well polished to facilitate its applica- 
tion. Smoothness of surface and freedom from cracks and crevices 
are conducive to cleanliness, but are not essential to asepsis if heat is 
employed for sterlizing. 

Of the numerous models of forceps, those most used in this country 
are the Simpson, the Wallace, the Hodge patterns, and the Elliott, a 
modification of the Edinburgh instrument. In England the forceps 
of Simpson and of Barnes, in France that of Pajot and of Dubois, 
and in Germany the Naegele and the Braun forceps are commonly em- 
ployed. 

Function of the Forceps. The essential function of the forceps is trac- 
tion. It is intended to replace or to supplement the natural expulsive 
forces. 

Fig. 389. 




The author's forceps. 

Its use as a compressor, a lever, or a rotator is seldom justified. 

Much compression of the head by forceps is dangerous to the child. 
This is especially true when the head is seized in an oblique diameter, 
which is frequently the case as the instrument is usually applied. 

Brain injuries, sometimes serious enough to cause the death of the 
foetus, are not infrequent results of instrumental delivery. Again, com- 
pression by forceps affords little or no mechanical advantage for extrac- 
tion, since in most seizures the reduction of one elongates the opposite 
transverse diameter. Moreover, when the forceps is applied in relation 
with the lateral walls of the pelvis the compression obtains in the direction 
in which there is usually most pelvic space and in which the reduction is 
least needed. 

It must be remembered, too, that the more rigid the grasp of the head 
the more the natural mechanism is interfered with. 

Moulding of the head is better trusted to the pressure of the pelvic 
walls, which applies compression only where it is needed, lengthens the 
head diameters only iu the direction of the birth-canal, and inflicts a 
minimum of injury. The intentional use of the forceps as a compressor 
must be condemned. The aim should rather be to make the pressure of 
the blades light enough, if possible, to leave no marks upon the child. 

42 



OBSTETRIC 8URQERY. 

A certain amount of compressive action, however, while undesirable; 
i-, nevertheless, unavoidable. It results necessarily from the grasp 
required to hold the handles, and it increases with the strength of the 

tractile force. It is evident that the risk of fcetal injury from pressure 
is diminished by a .-low and gradual delivery with the least possible 
expenditure of force. The compression should not only he gentle hut 
also he intermitted, as a rule, at frequent intervals. A forceps with short 
handles, having little compressive power, lessens the danger to the foetal 
head. 

The lever action of forceps is developed by pendulum movement- of 
the handles during traction. This is to some extent a mechanical gain, 
the resistance being overcome in detail. Less force is required to move 
down first one side of the head then the other than to move both 
together. This practice, however, is dangerous to the maternal soft 
parts, and is not to be recommended. That part of the wall of the pas- 
sages about which as a fulcrum the lever acts is bruised under the press- 
ure of the blade. These remarks refer especially to the lateral move- 
ments of the forceps practised by some operators. Swaying the handles 
in a sagittal direction is even more objectionable, since the passages are 
more liable to be injured by the edges of the blades than by their broad 
flat surfaces. A steady pull is best. Direct traction not only imitates 
the action of the natural powers, but it inflicts the least traumatism, and 
is all-sufficient for the purpose. 

As a rotator the forceps is a dangerous instrument. Attempts at cor- 
recting malpositions with forceps are almost certain to result in laceration 
of the passages. Twisting motions intended to promote the normal rota- 
tion of the head in forceps operations jeopardize the pelvic soft parts. 
This is true even of the straight forceps and especially so of instruments 
with the usual pelvic curve. 

Faulty positions should, if possible, be reduced by manual interfer- 
ence before the forceps is applied. In delayed rotation it is sometimes 
permissible to draw the leading pole forward with the fingers. With 
forceps the rotation of the head, while it must not be forced, should be 
favored. When the head has not been seized primarily in the biparietal 
diameter, the blades should occasionally be readjusted as the head 
descends, and care must constantly be taken that the influence of the 
natural agencies for producing rotation is not resisted. Most essential 
is a light grasp of the forceps near the lock, permitting the greatest pos- 
sible freedom of head movements. Rightly applied the blades will 
usually be kept in position by the pressure of the pelvic walls, and a 
strong hold upon the handles is not required to prevent slipping. 

Prerequisites and Contraindications to the Use of Forceps. Before resort- 
ing to forceps the obstetrician must satisfy himself that the following 
conditions are present : 

1. The relative size of the head and pelvis must be such as to make 
the extraction safely possible for mother and child. The election of 
forceps is not to be based on the pelvic measurements alone. The size 
and plasticity of the foetal head must be estimated. Approximate meas- 
urements of the head may be made with calipers through the abdominal 
wall. The presence or absence of disproportion may be determined, 
too, by noting whether the head has sunk into the excavation or can be 



THE FORCEPS. 659 

made to do so by suprapubic pressure, and, if necessary, by exploration 
with the hand in the uterus. Well-defined osseous obstruction or much 
narrowing of the canal from other causes should preclude the use of 
forceps. Its alternatives must be considered when the resistance is too 
great to be overcome without violent traction. 

2. The head must be of nearly normal size and consistence if it is to 
be securely grasped by the blades. The cephalic curve of the forceps is 
best adapted to heads of average size. An easily compressible head is 
equivalent to a small head. An undeveloped, a highly macerated, or a 
perforated head is not suited to forceps, a firm hold being impossible 
and the instrument liable to slip. In marked hydrocephalus and in 
excessive development from whatever cause, not only is the resistance 
too great, but the divergence of the blades is excessive and their grasp 
insecure. 

3. The child must be living and viable, except the extraction is to be 
an easy One. When the delivery of a dead child by forceps would be 
at all difficult, perforation should be substituted. 

4. The position of the head must be favorable. When possible, mal- 
positions are to be corrected by manual interference. This is not always 
practicable after the head has sunk deeply into the pelvis. A mento- 
posterior face position and generally an impacted occipito-posterior posi- 
tion forbid the use of the forceps. 

5. It is desirable that the head shall have engaged in the brim; in 
other words, shall have descended far enough to bring the biparietal 
diameter to the level of the inlet, or that it can be crowded down to that 
extent by suprapubic pressure. By many authorities forceps is rejected in 
favor of version before engagement. When the head is free above the 
brim the proper application of the blades is difficult or impossible. At 
best the cephalic mass will be caught obliquely by one side of the occiput 
and the opposite side of the sinciput. In this seizure not only is the 
pressure of the blades dangerous to the child, but it tends to bring about 
premature flexion and rotation, and thus to increase the resistance. Yet 
the widely accepted rule, version before and forceps after engagement, is 
subject to exceptions. This is especially true since the introduction of 
axis-traction instruments. When the waters have drained away and 
the foetus is firmly invested by the uterus, version is a difficult and 
dangerous operation. Forceps in such conditions often better serves the 
interest of both patients. In general, when the conditions are favorable 
for an easy forceps extraction, the latter is preferable to a difficult 
version. No attempt to apply the blades, however, must be made till 
the head has been pressed down as deeply as possible and so held by an 
assistant. 

6. The cervix must be fully dilated or easily dilatable, otherwise dan- 
gerous laceration of the lower uterine segment may result. In emer- 
gencies resort may be had, if necessary, to manual dilatation or to 
multiple shallow incisions of the lower border of the cervix. 

7. The membranes must be ruptured and retracted above the head. 
Should the membranes be caught in the grasp of the blades, the placenta 
may be prematurely torn partially or wholly from its attachment. 

Indications for Forceps. The necessity for forceps delivery may arise 
from anomalies (1) of the expellent forces, (2) of the passages, (3) of the 



660 OBSTETRIC srilGERY. 

passenger, or | \ in consequence of Bome complication of labor Independ- 
t'lii of t lie mechanism. 1 

1. Forces ai Fault, Failure of the pains is not of itself alone an indica- 
tion for forceps. I n the absence of complications dangerous to mother or 
child, the physician cannot justify himself in applying forceps to save 

his '>\\n time. Inertia uteri in the presence of conditions likely to jeop- 
ardize the interests of mother or child may call for instrumental delivery 
when simpler measures have failed. Sere, as elsewhere, forceps is justified 

when its dangers are less than those of delay. Important elements in 
the question are the strength and endurance of the mother as indicated 
by the force and frequency of the pulse, the presence or absence of 
exhausting pain, the quality and strength of the f<etal heart tones, and 
the probable difficulties of the operation. Impending exhaustion on the 
part of the mother is a frequent occasion for instrumental delivery. Just 
when forceps is permissible under this indication is- often a delicate 
question requiring the exercise of critical judgment. As a rule, when 
the head is low down in the passages and has been arrested for a half- 
hour because of feeble pains, the labor should be terminated with forceps. 

2. Passages at Fault. Marked osseous obstruction, as already observed, 
forbids the use of forceps. Yet moderate narrowing does not necessarily 
debar. The limit of contraction for forceps is variously stated by differ- 
ent authorities as from 8 to 9.5 cm., 3^ to 3f inches. But methods of 
treatment in deformed pelves cannot be formulated on pelvic measure- 
ments alone. The choice of procedure must rest on the relative size of 
head and pelvis. Pelvic contraction is an indication for forceps only 
when the plasticity and size of the head permit. The field of forceps 
is somewhat extended by axis traction and by the Walcher posture. Yet 
if the child is living and viable, symphyseotomy is generally better, in 
the interests of both patients, than a very difficult forceps delivery. 

As against version, in slight contraction, forceps has the advantage 
that under modern methods the pull is in the pelvic axis and the uterus 
is less exposed to both septic and mechanical injuries. It is easier to 
sterilize instruments than hands. 

Except at the cervix forceps is permissible in moderate obstruction in 
the soft parts. 

3. Passenger at Fault. Forms of foetal dystocia amenable to forceps 
are met with in occipito-posterior positions, in men to-anterior face cases, 
and in pelvic presentation with the breech arrested in the excavation. The 
instrument is superior to other methods in certain difficult extractions of 
the after-coming head. Evidence of foetal exhaustion or asphyxia, pulse 
above 160 or below 100 to the minute, may necessitate immediate instru- 
mental delivery. Forceps is contraindicated in high transverse positions 
of the face, owing mainly to the danger to the child from pressure of the 
blades upon the vessels of the neck. The delivery of a posterior-face 
case is impossible as such, and attempts at instrumental rotation are not 
permissible. 

4. Accidental Complications. Complications of labor sometimes de- 
manding forceps are hemorrhage, prolapsus funis, rupture of the uterus, 
eclampsia, and all acute and chronic diseases or other complications of 

i The indications for forceps will be found more fully treated under Anomalies of the Mechanism 
of Labor. 



THE FORCEPS. 661 

labor in which immediate delivery is required in the interest of mother 
or child or both. 

In general the low operation is frequently justifiable on minor indica- 
tions, the high operation only on major indications. 

Dangers of the Forceps Operation. Accidents to which the mother is 
exposed and which are not always preventable in forceps delivery are 
slight contusions and lacerations of the passages. Injuries to the uterus, 
to the vagina, and especially to the pelvic floor are more frequent than in 
spontaneous labors. Most liable to tear are the cervix and the vaginal 
orifice, since the resistance from the soft parts is usually greatest at these 
points. Serious accidents are, unfortunately, common in careless and 
violent forceps deliveries. A cervical tear may invade the uterus and 
enter the peritoneum. Pelvic floor injuries not infrequently destroy the 
recto-vaginal septum. Owing to faulty application or to unguarded 
traction, the blades may slip from the head either vertically or horizon- 
tally and be dragged abruptly through the passages. Even serious blad- 
der wounds and perforation of the posterior vaginal fornix may occur at 
the hands of the careless or the inexpert. If the handles are carried too 
far forward or backward during traction, the vaginal walls may be cut by 
the tips of the blades. Misdirected traction exposes the maternal soft 
parts to needless injury, and even rupture of the pelvic joints is possible 
in violent instrumental delivery. The difficulty of extraction may be in- 
creased in the unskilful use of forceps by hindering the normal mechanism. 

The danger is obviously greater the higher the head in the pelvis, since 
the control of the instrument is more difficult and injuries to the upper 
portion of the passages more serious. The head before it has fully 
engaged in the brim is imperfectly moulded, the grasp is bad, the normal 
head movements are impeded, and the difficulty of extraction is increased 
accordingly. 

To the child the risks of forceps delivery are greater than to the 
mother. Intracranial hemorrhage from injuries to the meningeal or 
cerebral vessels is not an infrequent result of compression in difficult, 
and this sometimes occurs in easy, forceps extractions. Injurious press- 
ure may arise from rapidly dragging an unmoulded head through the 
pelvis as well as directly from too forcible grasp of the blades. A con- 
siderable foetal mortality is attributable to these injuries, and permanent 
mental and physical infirmities may result in children who survive them. 
Hemiplegia, idiocy from cerebral atrophy, psychical disorders, and even 
epilepsy in later life are believed to be possible consequences of these 
lesions. The lower anterior angle of the parietal bone is the most vul- 
nerable point. 

When the cord is coiled about the child's neck it is exposed to press- 
ure from the tips of the forceps blades and fatal asphyxia may ensue. 
Facial paralysis results most frequently from compression of the facial 
nerve-trunks, but may occur from the pressure of an intracranial blood- 
clot. The former injuries are usually unimportant, the paralysis disap- 
pearing within a few days. Injuries to the brachial plexus have occurred 
in forceps operations, but probably from stretching the nerve-trunks 
rather than from pressure effects. Abrasions, indentations, lacerations, 
and contusions of the scalp, face, and eyeballs are common in instru- 
mental delivery. Yet anything more than slight or transient markings 



662 OBSTETRIC SURGERY. 

must be regarded as a reproach to the skill of the operator. Deep inden- 
tations of the skull or fracture of the cranial bones can result only from 
culpable ignorance or carelessness. 

Fatal asphyxia Is common after labors terminated with forceps. This 
may result from premature efforts at respiration provoked by peripheral 
irritation, or from the inhibitory effect of brain compression on the car- 
diac movements through irritation of the vagus. When head and pelvis 
are proportionate the skilful and timely use of forceps should, as a ride, 
diminish rather than increase the foetal mortality. 

Preparation for the Forceps Operation. The bladder and the rectum 
are t<> be emptied; either of these viscera if distended may suffer serious 
injury from the forceps. The cleanliness of the operation may be pro- 
moted by thoroughly washing out the lower bowel as a preliminary. 

The quality and the frequency of the foetal heart tones should be noted 
and should be listened for at intervals during delivery. An anaesthetic 
to the surgical degree is generally advisable, and for this purpose ether, as 
a rule, is to be preferred. In low operations mere obstetric anaesthesia often 
suffices, or none at all may be necessary. In all prolonged and difficult ex- 
tractions complete narcosis is required. The administration of the anaes- 
thetic should, if possible, be entrusted only to a skilful medical assistant, 
and should be managed in accordance with the usual rules of surgical 
practice. 

The abdomen, the thighs, and especially the external genitals are 
rendered as nearly aseptic as possible. Particular care is given to 
the cleansing of the vulva and its immediate surroundings. If the 
vagina is healthy and has not been exposed to unclean contact during the 
labor or for some hours before, no internal antisepsis is required. When 
the vagina or cervix is diseased or there is reason to believe they have 
been infected, the passages should be prepared with the same care as are 
the external genitals. They are scrubbed for five minutes with soft soap 
and hot water, with the aid of gentle friction, care being taken to prevent 
abrasions. The friction is best applied with the fingers or with a soft 
cotton ball held in the grasp of a suitable forceps. A sublimate douche 
1 : 4000, or other equally active antiseptic solution, is then to be employed 
for the same length of time, the friction being continued. The lubrica- 
tion of the parts may, if necessary, be restored by the plentiful use of 
sterilized glycerin or vaseline. In hospitals it is a common antiseptic 
precaution to cover the legs and feet with sterilized leggings or drawers. 
Wrapping them in aseptic sheets suffices, and this method is recom- 
mended in family practice where the leggings are not usually available. 

The operator's hands and forearms are to be prepared as for a major 
surgical operation. A sterilized operating-gown or, in the absence of 
this, an apron or a sheet should protect the physician's clothing against 
contact of his hands. The instrument is best sterilized by boiling. It 
may be wrapped securely in a towel before sterilizing, and so kept till 
wanted for use. A basin containing a bichloride solution, 1 : 2000, or 
other suitable antiseptic, and one or two squares of cheese-cloth should 
be provided. This serves for rinsing the hands as required and for 
cleansing the external genitals of the discharges. An ounce or two of 
glycerin or of vaseline which has been sterilized by heat may be found 
useful as a lubricant for hands and instrument. 



THE FORCEPS. 663 

The operation is most conveniently conducted on a firm table which has 
been properly cleansed, dressed, and covered with a surgically clean 
sheet. When the patient is delivered on the bed, as is usually the cus- 
tom in private practice, the mattress is protected with a rubber sheet, 
and the bed-linen and the patient's clothiug must be as nearly aseptic as 
possible. A small foot-tub or infant's bath-tub or slop-jar is placed on 
the floor at the edge of the bed to receive the discharges. A rug or a 
table oil-cloth spread under it saves soiling the carpet. 

Indispensable to a successful and safe forceps delivery is an exact knowl- 
edge of the position of the foetal head. In case of the slightest doubt 
or any possibility of error, the diagnosis of position should be confirmed 
by passing the hand, if necessary, into the uterus. Finding an ear may 
suffice for determining the foetal position, but, as a rule, the entire head 
should be examined. This examination can best be made after the 
patient has been placed under the anaesthetic. With the aid of anaes- 
thesia and with the hand in the uterus it is possible in every case to know 
with absolute certainty the position of the head. 

The cervix must be fully dilated or so soft and yielding as to permit 
the passage of the head without risk of tearing. Dilatation may be com- 
pleted if necessary with the hand or by means of a w T ater-bag, and even 
multiple incisions to the depth of half an inch are permissible in emer- 
gencies requiring prompt delivery. 

Posture of the Patient. In this country, in France, and in Ger- 
many the position generally preferred for ordinary forceps delivery is the 
partial or complete lithotomy position. The patient is placed on her back 
across the bed with the thighs and the legs flexed, and the knees held 
apart, the hips extending over the edge of the bed, or in a similar posi- 
tion on a firm table. One assistant on each side is usually necessary for 
holding the limbs. In the absence of assistants a crutch or Dickinson's 
sheet-sling may be utilized for the purpose. 

The left lateral position is usually adopted in England for forceps 
delivery, and is known as the English position. 

Walcher's Position. It is well known that the sacrum, especially in 
in the later months of pregnancy, is capable of a slight nutatory motion 
on a transverse axis passing through its second vertebra. Walcher, in 
1889, called attention to the importance of utilizing the mobility of the 
sacro-iliac joints in difficult labor. The sacral promontory lies in a plane 
above the axis of rotation and in front of it. The promontory, there- 
fore, moves forward and backward according to the changing inclination 
of the pelvis in different postures of the body, and the tip of the sacrum, 
of course, moves in reverse direction. When the woman lies in the lith- 
otomy position, the thighs being strongly flexed upon the abdomen, the 
conjugate diameter of the pelvis is shortened; when placed in the dorsal 
position with the hips close to the edge of the table and the lower 
extremities hanging, that diameter is lengthened. The latter posture is 
known as Walcher' s position. (See Plate XL) The gain in the con- 
jugate on changing from the lithotomy to the Walcher position is variously 
estimated at from 5 to 13 mm. In a series of observations made by the 
writer the increment was, in the cadaver of the non-puerperal subject, 3 
mm., and in the living woman within two weeks after labor, from 5 to 7 
mm. The gain, though small, may be utili2ed to advantage in moderate 



GU4 



OBSTETRIC SURGERY. 



disproportion between head ami pelvis. In difficult extractions the 
patient should be placed with the thighs in full extension till the largest 
circumference of the head has passed the brim. On the other hand, the 
dorsal recumbent posture, thighs moderately flexed and knees held apart, 
and especially the extreme lithotomy position is best daring the extrac- 
tion of the head through the outlet of the bony pelvis. 

The Operation. The operation is spoken of as high, low, or medium, 
according to the situation of the head in the passages; it is high when 
the head is at the superior strait or barely engaged therein, low when it 
rests on the pelvic floor, and medium in intermediate situations. These 
operations differ in the extent and character of the manipulations 
involved, not only by reason of the changing direction of the birth- 
canal, but also because of the varying positions of the foetal head at 
different stages of descent. Low forceps delivery is a comparatively 
simple undertaking; the high operation is one demanding the utmost 
skill and tact. 

Fig. 390. 




Cephalic application of forceps over the parietal eminences. (Farabeuf and Varnier.) 



The Application of the forceps may be cephalic or pelvic. In the 
former the head is seized transversely, the blades resting over the pari- 
etal eminences (Fig. 390); in the latter the blades are applied in rela- 
tion with the sides of the pelvis without reference to the head. 

Application to the sides of the head has the following advantages : 
The grasp is symmetrical, the blades fit better, they do less injury to the 
head, the normal mechanism is less disturbed. 

When the blades are applied to the sides of the pelvis the head is 
usually caught obliquely; in high applications the grasp falls over one 



THE FORCEPS. 665 

frontal bone and the opposite side of the occipital — a direction in which 
compression is especially harmful and the grasp liable to be insecure. 

On the other hand, the pelvic application of forceps is simpler and 
easier than the cephalic, and in inexperienced hands least endangers the 
soft parts of the mother; if the handles are held lightly and the traction 
is intermittent, the pressure on the head is usually well borne. 

In low operations, rotation being complete or nearly so, application to 
the sides of the pelvis brings the blades at the same time in relation with 
the sides of the head. It is only in high or medium cases that the choice 
of methods must be considered. In high operations the difficulty and 
danger of the cephalic application are, as a rule, too great to justify the 
inexperienced operator in attempting it. On the whole, the beginner will 
do well to content himself, as the vast majority of physicians in general 
practice do, with the pelvic application of forceps. The expert will 
best serve the interests of both patients by electing the cephalic. When, 
however, it becomes • necessary to bring the head down through the 
brim, the blades are to be first adjusted in a transverse diameter of the 
pelvis; after the head has entered the excavation the instrument may be 
readjusted or removed and reapplied over the parietal bones. 

Steps of the Operation. The operation comprises four steps : The 
introduction of the first blade; the introduction of the second blade; lock- 
ing the forceps; the extraction of the foetus. 

Application with reference to the pelvis, the method most commonly 
pursued, will first be considered. It will be assumed that the head is in 
an anterior position. 

1. Pelvic Application, (a) Introduction of the First Blade. If 
hands and instrument are wet with the antiseptic solution no other 
lubricant, as a rule, is required; should any be needed vaseline or glycerin 
previously sterilized by heat may be used. The latter is the more cleanly. 

For convenience in locking, the left, since it is the lower arm of the 
forceps, is usually passed first. The operator sits or stands as may be 
most convenient. The patient in position and all preparations complete, 
he introduces two or more fingers of the right hand into the vagina with 
their volar surfaces facing his left. They are pushed upward and back- 
ward between the head and the left wall of the passages. If the head 
is still in the uterus care will be required to make sure that the fingers 
are passed within the cervix. The finger tips are carried as far as they 
will readily go, and the cervix is held well outward away from the head. 
The nearer the head to the vulvar orifice the greater the difficulty and 
the less the need of pushing the guiding fingers deeply in the pelvis. 
The left branch of the forceps is now taken in the left hand and the 
blade is introduced, the palmar surface of the hand in the passages serv- 
ing as a guide. The arm is at first grasped near the lock and is held 
lightly between the thumb and finger and in a nearly vertical direction 
(Fig. 391). If a firmer grasp is required as the blade passes alongside 
the head the handle may be held in the full hand. The instrument is 
pushed gently on in the direction of the passage till it reaches the head. 
From this point the course of the blade is that of a spiral ; it must follow 
both the pelvic and the cranial curves. After it has passed beyond the 
reach of fingers it is guided by hugging the head with the tip. Urged 
cautiously along it finds its own way, moving in the direction of least 



666 OBSTETRIC 8XJBQEB V. 

resistance. No force is necessary or permissible. Should any obstacle 
be met it must no1 be overcome by increasing the pressure; the blade 
should be partially withdrawn and its direction slightly altered till it 
Blips easily into place. It is carried well up till the tip barely over- 
reaches the head, should a uterine contraction occur, the manipulations 
should !)e suspended till it ceases. Usually under anaesthesia the pains 
are in abeyance. 

Fig. 391. 




Application of first blade of forceps. (Zweifel.) 

(b) Introduction of the Second Blade. The right half of the forceps 
is held in the right hand and the blade passed on the left hand as a 
guide, in a manner entirely similar to that already described for the first 
blade. The handle of the first arm may, meantime, be held by an assist- 
ant, or be left to itself (Fig. 392). The application of the second blade, 
while not so easy as the first, is not, as a rule, difficult. 

(c) Adjustment and Locking. The operator now seizes one handle in 
each hand, the thumbs being extended along the upper surface. If the 
blades are properly applied the two halves of the instrument will fall 
into symmetrical positions and will lock easily. If the handles do not 
face each other, push them well back against the perineum; should one be 
higher than the other, push the lower one gently up. In high operations 
it will always be necessary to press the handles as far back as the peri- 
neum will permit. The locking must never be forced. If difficulty is 
still encountered, the blades should be removed or partially withdrawn 
and repassed. With a good seizure, the head being of normal size, the 
handles, while they are not in contact, will not be far apart. A common 
mistake in the application of forceps consists in failing to pass the blades 
far enough. The aim should be to bring the head well within the cra- 
nial curvature of the instrument. Care must be taken that the grasp is 
not too far forward or backward, and that it does not include a loop of 



THE FORCEPS. 



667 



the cord. As the arms are locked a finger is swept around the shanks 
to prevent catching the labia or vulvar hairs between them. 

2. Cephalic Application. It is assumed that the head has passed 
the brim or is in the excavation. The anterior blade, whether that be 
the right or the left, because the more difficult of application, is usually 
passed first. The difficulty of manipulation would be rendered still 
greater by the presence of its companion in the passages. The guiding 
fingers are carried up along the anterior side of the head as far as they 
can reach, finding the place where there is most room. The blade is 
then introduced, and, with the aid of one finger hooked under the front 
or the back rim of the fenestra, is then gently urged sidewise into 
position over the parietal eminence. With changed hands the posterior 

Fig. 392. 




Application of second blade. (Zweifel.) 



blade is applied in like manner over the opposite parietal bone. The 
internal fingers, pushed up as far as possible between the posterior side of 
the head and the sacro-iliac ligament, guide the blade to its destination. 
When the right arm has been applied first the handles must be readjusted 
for locking. 

If the forceps is in proper relation to the head it will lock readily. 
It will now be seen that the handles do not lie in the median plane, as 
they do when applied to the sides of the pelvis. In high applications 
they will be found nearly or quite in line with the oblique diameter of 
the pelvic brim, facing strongly to one side. W'hen the head is deeper 
in the pelvis they look more nearly forward. 

(d) Extraction. The forceps being locked, the operator examines to 
assure himself finally that the blades are in proper relation with the head. 
The force and frequency of the foetal heart are noted and are listened for 
at intervals during delivery. 

In easy extractions the pull is applied with one hand while a finger of 



668 OBSTETRIC SURGERY. 

the other is held againl the head to give warning Bhould the instrument 
slip. When more force is required both hands are used for traction, and 
examinations are made in the intervals. 

(a) In Low Operations. In low operations the delivery is effected for 
the most part or wholly under ocular inspection. With the head well 

down on the pelvic floor and in anterior position but little tractile force 
is needed, and the risks of either foetal or maternal injuries are insignifi- 
cant. The forceps is grasped with one hand near the lock, the first and 
second lingers hooking over the projecting shoulders at the upper ends of 
the handles. The least possible compression is thus exerted upon the 
head. In many cases none is required to maintain the grasp. The walls 
of the birth-canal, as a rule, make sufficient pressure to keep the blades 
in place when the seizure is good and little tractile force is employed. 
The palm of the hand may be turned up or down. 

The tractions, like the natural pains, should be intermittent. They 
should continue for about one minute, and the intervals may be one or 
two minutes. Duriug the intervals the forceps is unlocked to relieve the 
head from pressure. The line of traction must be such that the blades 
are kept constantly in the axis of the birth-canal. 

The extraction of the head may or may not be completed with the 
forceps. The thickness of the blades is too small to make any appre- 
ciable difference in the distention of the pelvic floor, yet too great strain 
may be brought upon the resisting soft parts by misdirection of the trac- 
tile force or by disturbance of the normal mechanism of expulsion even 
at the hauds of an expert. Injury may inadvertently be done by drag- 
ging the head too heavily against the pelvic floor or by too rapid exten- 
sion. The writer prefers, therefore, to remove the forceps, as a rule, 
when the head has descended so far that it no longer recedes in the inter- 
vals between tractions. The head is then easily expelled by light press- 
ure applied from behind through the perineum. With the fingers of one 
hand upon the occiput and w r ith the other hand laid flat upon the bulging 
surface well back of the posterior vulvar commissure, thumb to one side 
and fingers to the other of the genital fissure, the advance of the head 
is perfectly under control. On no account are the fingers to be intro- 
duced into the rectum for the purpose of shelling out the head. The 
practice is unnecessary and is incompatible with a strict asepsis. 

The forceps blades are removed in the reverse order of their applica- 
tion. Two fingers of one hand are applied over the anterior edge of the 
blade just within the vulva to protect the maternal soft parts. As the 
blade is withdrawn the handle is gradually swept well up over the oppo- 
site groin. Should an obstacle be encountered the blade must not be 
forcibly extracted. If the obstruction cannot be overcome by slightly 
changing the direction of the blade, the latter may be left in place till 
the head is delivered. 

If delivery is completed with forceps the natural mechanism of expul- 
sion must be closely followed. The head is drawn down till the nucha 
is well under the pubic arch. Then by an upward movement of the 
handles the forehead, the face, and the chin are made to sweep in succes- 
sion over the vulvar edge. (Fig. 393.) 

The handles may be held forward during the perineal stage of the 
operation as far as possible without bruising the soft parts between the 



THE FORCEPS. 



669 



anterior edges of the blades and the ischio-pubic rami. This will neces- 
sitate carrying the handles more and more forward and upward as the 
head descends, till at the moment when it escapes they are almost in 
contact with the mother's abdomen. After the pelvic floor begins to 
bulge the instrument is held by the shanks near the lock with the radial 
edge of the hand up. 




Showing the normal course of the head in its descent through the birth-canal. 
(Farabeuf and Varnier.) 



If in doubt as to the extent to which the handles should be swept for- 
ward, let go the handles and observe their position. If the blades are 
in proper relation to the head, the direction which the handles assume 
when left to themselves will be that in which they should be held during 
traction. 

During the perineal stage of the operation the head should be pressed 
well up into the pubic arch. The perineum and anal orifice are covered 
with a sterile towel. Over this the hand is held broadly across the 
bulging pelvic floor, the thumb lying along one side and the fingers along 
the other side of the vulva. Firm pressure is made toward the pubic 
arch during traction. This manipulation aids materially in preventing 
pelvic-floor injuries by relieving the fascial structures of the floor of 
excessive strain during extraction of the head. 

In artificial as in spontaneous births time is an important element in 
the prevention of perineal injuries. The extraction must be slow and 
gradual to permit the pelvic floor to stretch. In primiparse, as a rule, 
a half hour will be required for this stage of the delivery, and little less 
in most other cases. 

(b) In High Operations. As a general, if not an invariable, rule, 
axis-traction forceps should be substituted for the classical instrument at 
the superior strait. If the ordinary forceps is used both hands are 
usually required for traction. If a straight pull upon the handles is to 



670 



OBsr/:ri:ic suikiery. 



be employed they may face each other with the handles flatwise between 
i hem. The first two fingers of one hand are hooked over the transverse 
projections and upon these fingers rest the corresponding ones of the 
other hand. The remaining fingers of one hand encircle the handles, 
holding them lirmly enough only to prevent the blades from slipping. 
When the instrument is rightly applied little or no compression is 
necessary. 

Bui to act to the best advantage the tractile force must be applied as 
nearly as possible in the axis of the birth-canal. A straight pull on 
the handles wastes a part of the force by dragging the head against the 

Fig. 394. 




Head at superior strait ; right and wrong traction. (Farabeuf.) 

anterior pelvic wall (Fig. 394), and the misdirected force is not only lost, 
but is mischievous. It increases the resistance and adds to the risk of 
both maternal and foetal injuries. Yet with an instrument of mode- 
rate pelvic curve the disadvantage of direct traction on the handles is 
insignificant in easy forceps deliveries. 

Axis traction is possible with the common forceps by Pajot's (Gala- 
bin 7 s) manoeuvre, which is executed as follows : The handles are held 
lightly with one hand near the lock, to avoid much compression, and the 
other hand is applied upon the shanks near the vulva. Pressing down- 
ward with the hand on the shanks while the other pulls upward at the 
handles, the two forces may be so balanced that the resultant shall act in 
the line of descent. If the operator stands by the bed or table, the hands 
are applied above the instrument with the palmar surfaces down (Fig. 
395); sitting the hands grasp the handles palms upward (Fig. 396). 
The mechanical principle involved is also set forth in Fig. 397. 

Line of Pull. A straight line passing through the umbilicus and the 
tip of the coccyx is practically the line of pull till the head reaches the 
pelvic floor; this line is parallel with the posterior surface of the sym- 



THE FORCEPS. 



671 



physis pubis, which may be taken as the guide. For greater accuracy 
the direction may sweep very slightly backward in conformity with the 
curvature of the sacrum. In all high operations, and especially in pelvic 
distortion, where we have no reliable anatomical guides to the axis of the 
bony canal, the axis-traction instrument, which itself points out the way 



Fig. 395. 




Axis traction with plain forceps, operator standing. (Pajot's manoeuvre.) 
Fig. 396. 




Axis traction with plain forceps, operator sitting. (Pajot's manoeuvre.) 

and at the same time permits the greatest possible freedom of head move- 
ments, offers an obvious advantage. 

As soon as the pelvic floor begins to bulge under pressure of the 
advancing head the line of direction turns somewhat abruptly forward. 
From this point the technique does not differ from that of the low opera- 
tion already described. 

The amount of tractile force should not exceed eighty pounds; in the 
Pajot method it can scarcely reach that limit at the hands of most oper- 
ators. In the writer's experience the strength of pull as measure red by 
a dynamometer attached to an axis-traction instrument, has not in the 



672 



OBSTETRIC SUBQEBT. 



most difficult of justifiable forceps deliveries exceeded seventy pounds. 
In a properly conducted forceps operation the force employed will seldom 

be more than twenty-five or thirty pounds, and it will rarely amount to 

fifty pound-. 

Traction should be made with the arms only. Bracing the feet and 
pulling with the weight of the body is neither necessary nor permissible. 
The beginning traction should be tentative to make sure that the head is 
properly in the grasp of the blades and that no unusual obstacle or diffi- 
culty is present. 

Since the high operation must be conducted under full anaesthesia, no 
aid is to be expected from the natural pains. Well-directed abdominal 



Fig. 397. 




Showing the mechanics of axis traction with plain forceps. (Farabeuf and Varnier.) 

pressure, however, at the hands of a skilled assistant is an efficient help. 
This may be continued with advantage till the head is well down on the 
pelvic floor. 

The rule of a pull and a pause, of about one minute each, should be 
observed, and the forceps be unlocked in the intervals between tractions 
to relax the pressure upon the head. 

General Mules. The normal mechanism of labor must be strictly ob- 
served throughout the descent. As soon as the equator of the head has 
passed the brim rotation begins. While the forward movement of the 
occiput must not be forced it may be favored. When the blades have 
been applied in relation with the sides of the pelvis, they must be read- 
justed as the head rotates in course of its descent. 



THE FORCEPS. 673 

While the head is passing the superior strait the possible advantage of 
the Walcher position should be borne in mind. Traction should be mod- 
erate, permitting time for moulding of the head. As already stated, the 
cervix, as a rule, should be fully dilated, manually if need be, before the 
application of forceps. Yet the tension of the cervical ring must be 
watched during traction, and time must be allowed for it to yield gradu- 
ally should dilatation prove not to have been complete. If the cervix 
is drawn down to the vulva it may gently be pushed back over the head 
with the fingers of one hand, while moderate traction upon the handles 
of the instrument is applied with the other. 

(c) In Medium Operations. The method of procedure in cases inter- 
mediate between the high and the low operation scarcely needs discus- 
sion. It should be remembered that in the typical relation of head to 
pelvis the sagittal suture approximates the antero-posterior diameter of 
the pelvis only when the head has reached the outlet of the soft parts. 
In the latter situation the blades applied with reference to the pelvis fall 
directly over the biparietal diameter. The higher in the pelvis the more 
oblique will be the seizure of the head in the pelvic application of the 
instrument. 

Forceps in Occipito-posterior Positions. In posterior positions of the 
vertex before engagement forceps is inadmissible. It is the writer's 
practice, if the head is movable at the brim or can readily be pushed up, 
to rotate not the head alone but the entire foetus into dorso-anterior posi- 
tion. Before rupture of the membranes this is frequently possible by 
external manipulation. If the waters have escaped one hand is carried 
into the uterus to the posterior shoulder, which is swept outward away 
from the median line, the anterior shoulder at the same time being urged 
inward toward the median line by the external hand over the abdomen. 
This is done with the aid of full anaesthesia. After bringing the occiput 
to the front the head is crowded into the pelvic brim by external press- 
ure, and the forceps then applied, if necessary. 

If the head has engaged too firmly to permit correction of the mal- 
position, forceps should be withheld as long as possible. In general, 
rotation may safely be awaited so long as the pains are good, the pelvic 
floor resilient, and the conditions of both patients such as to justify delay. 
Except in extreme emergencies, simple measures should be exhausted 
before resorting to instrumental delivery. The operation is more diffi- 
cult and is much more dangerous to mother and child than when the 
occiput confronts the anterior half of the pelvis, and must not be lightly 
undertaken. When forceps must be used, application to the sides of 
the head is always desirable, yet it is more difficult than in anterior 
positions. Generally, it will be found best to introduce the anterior 
blade first, whether that be the left or the right one. 

No effort must be made at rotation with forceps. The attempt will 
almost surely result in injury to mother and child. A moderately firm 
grasp will be required to prevent slipping (Fig. 398). 

In occipito-posterior positions the arrest of the head frequently means 
imperfect flexion. To bring down the occiput, when flexion is incom- 
plete, the line of traction should be somewhat in front of the pelvic axis 
till the forehead clears the pubic arch (Fig. 399). The occipital pole 
may then be lifted over the vulvar edge with the forceps. The writer, 

43 



674 



OBSTETRIC 8UBGEBT. 



however, prefers to remove the forceps when the head lias reached the 
vulvar outlet and complete the delivery by manual measures. Jn must 
Oases it i- possible after the head is well in the grasp of the vulvo- 
vaginal ring to rotate the Occiput to the front by manual interference. 

Under backward pressure with the fingers of one hand against the ante- 
rior temple, rotation usually takes place with the utmost facility. The 

Fig. 398. 




Relation of forceps to head in occipito-posterior position, head well flexed. 
(Farabeuf and Varnier.) 

posterior pole of the head may at the same time be drawn forward with 
the other hand, if necessary. Even should the rotation be difficult there 
is little risk of doing harm to either mother or child by properly directed 
mauual efforts. It is commonly stated that the foetal head cannot be 




Occipito-posterior position, flexion incomplete. Forceps applied over mastoid and pulling forward 
to increase flexion. (Farabeuf and Varnier.) 

turned for more than a quarter circle without danger of injury to the 
atlo-axial articulation. But Tarnier has called attention to the fact that 
the torsion is distributed along the eutire upper portion of the spinal 
column, and may safely be carried, therefore, beyond a quarter circle. 
Exaggerated rotation, he thinks, is less dangerous than the excessive 
flexion necessary to delivery in the posterior position of the occiput. 

Rotation failing, the delivery is completed with forceps, in accordance 
with the usual mechanism of persistent occipito-posterior positions. 



THE FORCEPS. 



675 



Forceps in Face Presentation. In mentoposterior face cases forceps is 
contraindicated. In an impacted face position symphyseotomy should 
be considered if the child is living and viable, otherwise the head should 
be perforated. 

In low mento-anterior face positions forceps delivery presents no spe- 
cial difficulty. Judicious attempts at manual rotation are permissible, 
if necessary, but no twisting or rotating force must be used with the 
forceps. Extension must be maintained and the mechanism of natural 
delivery be carefully followed. The only safe application is to the sides 
of the head, and care is necessary to secure a firm hold, reaching well 
back to prevent slipping. Any other seizure endangers the child by 
pressure upon the neck, and, moreover, is insecure. Traction is made 
horizontally till the chin is brought well under the pubic arch; then by 
raising the handles the face, the vertex, and the occiput are successively 
swept over the perineum. 

Forceps to Breech. Forceps, while not well adapted to the breech, is, 
in certain cases of this presentation, the best available means for extrac- 
tion. When the pelvic end of the foetal ovoid has so far engaged that 
a foot cannot be brought down, yet has not sunk deeply enough in the 
excavation to permit the successful use of finger or fillet, the forceps may 
be tried. The axis-traction instrument is to be preferred, especially in 
high operations. The best application is that of Ollivier : one blade 
resting over the sacrum and one ilium, the other over the posterior sur- 
face of the opposite thigh. 



Fig. 400. 




Extraction of the after- coming head with forceps. 

Manual rotation is sometimes possible when the position is not pri- 
marily suitable for a satisfactory seizure. When the breech is fixed 
transversely in the pelvis, the blades may be placed over the trochanters. 
Application over the iliac crests is recommended by some writers, but 
these bony prominences are compressible, and the tips of the blades are 
liable to injure the abdomen. In all applications to the breech it is 
difficult so to regulate the grasp as to make the hold secure and at the 
same time to prevent injurious pressure. The amount of tractile force 
should be kept at a minimum by pulling only during the pains and by 



676 OBSTETRIC SURGERY. 

the belp of abdominal pressure applied by an assistant over the fundus. 
[f the child ie dead a firm grasp is permissible. 

Forceps to After-coming Head. In all cases of breech extraction the 
forceps should be in readiness for instant use in cases of difficulty in 
extracting the after-coming head. The forceps in head-last births, while 
seldom necessary, is the most effective of all methods of delivering the 
head. The application is attended with no difficulty, The body of the 
child should he held up over the abdomen of the mother and the blades 
passed beneath the foetal trunk (Fig. 400). 

Head Separated from the Trunk-. It may become necessary to extract 
the detached head from the uterus after decapitation or when the head 
has been torn from the trunk and left behind through unskilful use of 
traction upon the trunk in breech births. Frequently, with the aid of 
suprapubic pressure, the delivery is possible without resort to instru- 
ments. In forceps as in manual extraction, the chin in such cases should 
first be brought down and so held during the delivery, to keep the long 
diameter of the head in the axis of the uterus. 

Axis-traction Forceps. 

An obvious defect in the classical forceps is the fact that in a straight 
pull upon the handles the tractile force is not applied in the parturient 
axis. The head as it is drawn down is dragged against the anterior soft 
parts of the birth-canal (Fig. 394.) 

By Pajot's manoeuvre this fault in the ordinary forceps is obviated in 
part but not wdiolly, since it is impossible to estimate precisely the direc- 
tion of the pelvic axis. Several devices have been proposed with a view 
to accomplishing axis traction. Among these may be mentioned the 
forceps of Galabin, with the handles bent backward, Hubert's forceps, 
in which the traction is made at the end of a rigid arm projecting back- 
ward at a right angle from the shanks, and Poullet's forceps, in which 
the pull is applied by means of tapes passed through apertures in the 
blades. All these instruments are open to the objection that the line of 
pull is left to the judgment of the operator, and they do not, therefore, 
insure precision in the right line of traction. 

Another and perhaps a more serious defect in the common forceps is 
the fact that its rigid grasp interferes to a greater or less extent with 
the natural movements of the head. In this particular, as in the line of 
pull, it is in high operations that the ordinary instrument is at its greatest 
disadvantage. This fault, like the first, loses much of its importance at 
the hands of a skilful operator, yet is by no means wholly obviated even 
by the most expert management. After the head has reached the pelvic 
floor the mechanism is less complex and its regulation more easily at 
command of the operator. 

In 1877 Tarnier, of Paris, gave to the profession an axis-traction for- 
ceps which, as since modified, has been widely adopted. In this instru- 
ment each arm, which does not differ essentially from the ordinary pattern, 
is provided with a slender traction-rod which is attached by a movable 
joint to the heel of the blade and terminates below near the lock. The- 
oretically the rods should pull from the centres of the blades, since trac- 
tion from these points would involve no directive action on the head. 



THE FORCEPS. 



677 



But to place the traction studs at the centre of the blade it would be 
necessary to insert in the fenestra a transverse bar, which would be liable 
to injure the head. The stud is, therefore, located at the heel of the 
blade. This construction, while not theoretically perfect, practically 
answers all requirements. The rod runs along the under edge of the 
shank, and when not in use is held in place by a. pin against which it 
rests at its lower end. After the blades are applied and the instrument 



Fig. 401. 




Tarnier's axis-traction forceps. 



locked the necessary compression is maintained by means of a fixation 
screw attached to the handles. The use of the fixation screw, however, is 
not always necessary. The lower ends of the traction rods are released from 
the shanks and are locked to a traction handle. The latter consists of 
a single rod bent strongly backward and armed at its lower end with a 
cross-bar for convenience in pulling. The construction of the instru- 
ment is such that when the lower ends of the traction rods are held 
about two-fifths of an inch away from the forceps shanks the line of pull 
will be in the axis of the blades, and, therefore, in that of the birth-canal. 
A movable joint at the cross-bar and the one at the attachment to the 
blades permit the utmost freedom of head movements. The blades when 
properly applied maintain their normal relation to the axis of the pas- 
sages as the head descends. The application handles change their direc- 
tion with the changing direction of the blades in course of the descent, 
and thus serve as an index of the right line of traction. 

Lusk's axis-traction forceps differs from the Tarnier model mainly in 
being lighter. In the Simpson pattern the traction apparatus is attached 
to the ordinary Simpson forceps. Murray has made a special study of 
the principle of axis traction from a mathematical stand-point, and has 
enunciated a formula for the construction of the instrument. Reynolds 
and others have devised traction rods to be attached to ordinary forceps; 
but these appliances only approximately accomplish their object. The 



678 



OBSTETRIC SURGERY. 



axis-traction forceps of the writer is constructed oo the formula of Milne 
Murray, bu1 is much Lighter (Fig. 403). A model used for several years 

Weighs, without traction rods and handle, only sixteen ounces, vet has 

proved equal to all requirements. 



Pig. 402. 




Mechanics of axis-traction forceps. 

Pulling at the traction-handle in the direction indicated by the lower arrow, the line of traction is 

in the axis of the blades, as shown by the upper arrow. (Farabeuf and Varnier.) 

The superiority of axis-traction forceps over the simple instrument, as 
commonly accepted, depends upon two things : 1. Pulling as it does directly 
in the line of descent all the tractile force is utilized. 2. The blades being 

Fig. 403. 




Jewett's axis-traction forceps. 
K. Lock for attaching traction-handle to rods. 



free to follow the natural movements of the head, the normal mechanism is 
not disturbed. Delivery is thus accomplished with the least possible 
amount of traction and with a minimum of maternal and foetal injuries. 
The facility with which the Head may be brought down with axis-traction 



THE FORCEPS. 679 

forceps is often in striking contrast with the difficulty frequently encoun- 
tered in delivery with the classical instrument. Breus, however, denies 
that the value of the Tarnier forceps depends in any degree on the axis- 
traction feature, and attributes it solely to the movable joints of the trac- 
tion rods and the consequent freedom of the head movements. His own 
instrument consists essentially of a simple forceps modified by the intro- 
duction of a movable joint between the blades and the shanks. A pair 
of rods rigidly attached to the blades and projecting in front of the 
shanks serves to indicate the position of the blades (Fig. 404). 

Pig. 404. 




Breus' Forceps. 

Murray and Naegele claim the same advantage for axis-traction appa- 
ratus in low as in high operations. In the writer's experience, pelvic-floor 
injuries have occurred more frequently when the delivery was completed 
with Tarnier' s than with the common forceps. The axis-traction instru- 
ment offers no advantage after the head has passed the inferior strait. 
Below this point the special tractors may best be disused and the delivery 
be managed as with simple forceps, or the latter be substituted. 

Operation. The blades are best applied with the patient in the usual 
dorsal recumbent position. For extraction she may lie on the back 
if the operation is conducted on a table; on a low bed she should 
be turned upon the left side. Walcher's position may be utilized in 
difficult extractions. After the forceps has been adjusted and locked, 
the application handles are grasped with one hand firmly enough barely 
to bring the blades in contact with the head. The fixation screw is then 
set to maintain the pressure thus obtained, but must not be used for com- 
pression, owing to the difficulty of correctly estimating the amount of 
force applied. The use of the screw, however, is not always necessary. 
When employed it should be released in the intervals between tractions. 

The pull is applied at the traction bar with one hand, while a finger of 
the other is held against the head to give warning should the blades begin 
to slip. Very rarely will it be necessary to use both hands for pulling. 
The traction rods must not be allowed to rest against the shanks of the 
forceps, but should constantly be held in a position just free from them. 
As the head descends the application handles move forward, and thus 
indicate the changing direction in which traction is to be made. 

When the head has been brought down to the pelvic floor the traction 
handle is detached and the delivery completed as with the ordinary for- 
ceps, or the classical instrument may be used if preferred. 



CHAPTEE XXXII. 

VERSION. 

By version we understand such an alteration in the Ideation of the 
foetus thai its long axis coincides more or less completely with thai of 
the uterus: this may be accomplished, first, by external manipulation ; 

secondly, by external and internal manipulation combined ; and, thirdly, 
by the introduction of the hand within the uterus. 

Indications and Limitations. In general, the indications for version 
are a transverse position of the foetus, an unfavorable presentation of 
the head which renders spontaneous birth impossible, contraction of the 
pelvis of such a kind that the head can best pass when preceded by the 
body, and some condition of the mother and child which demands rapid 
delivery, and will not permit the delay inevitable when birth is accom- 
plished in head presentations. We shall later, in this paper, compare 
the operation of version with other obstetric procedures, and endeavor 
to discriminate and to describe the positive indications for its employ- 
ment. 

That version, however performed, may be successful, certain condi- 
tions must be present. The amniotic liquid must be wholly or in part 
retained within the uterus. Spasmodic and persistent contraction of 
the uterine muscle, known as tetanus of the uterus, must be absent. 
The lower uterine segment must not be excessively distended, as shown 
by the complete development and high position of the contraction-ring. 
The necessary assistance and appliances for anaesthetizing the patient, 
for the thorough practice of antisepsis, and for the resuscitation of the 
child, must be available. To succeed in difficult cases, the operator 
must be thoroughly familiar with the anatomy of the birth-canal, and 
must be possessed of sufficient skill and strength to perform the man- 
ipulations required. Especially unfavorable conditions are experienced 
in cases in which the amniotic liquid has long been drained away, the 
uterine muscle being spasmodically contracted, the vulva and vagina 
narrow and rigid, the child excessive in size, and one or more foetal 
Limbs w r edged into the pelvic brim with the trunk or head of the 
foetus. 

As performed in average cases, the operation carries with it no great 
risk to the mother; but when followed by rapid extraction of the foetus, 
it exposes the latter to considerable danger from birth-pressure or as- 
phyxia. The field of version has been considerably lessened of late 
through the extensive use of axis-traction forceps, the practice of sym- 
physiotomy, and the perfection of Csesarean section. It still remains, 
however, a most valuable operation, and especially for the practitioner 
who has but limited assistance and is without the apparatus employed 
in the more complicated procedures. 

External Version. By external version is meant the turning of the 

(6S0) 



VERSION. 



681 



child by external manipulation only ; this may be accomplished in such 
a way as to bring the head to present at the pelvic brim, or to cause 
the head to ascend and the breech of the child to present at the pelvis. 
The most favorable time for this procedure is just before the commence- 
ment of active labor, or, at latest, before the amniotic liquid has in any 
quantity escaped. 

Indications. External version is indicated in cases where a breech 
presentation is diagnosticated during pregnancy, or where the foetus 
presents by the head, but the conditions are such that its birth in breech 
presentation would be more favorable for mother and child. It is also 
advisable in cases in which the foetus is oblique in the uterus, the brow 
resting against the pelvic brim, or the occiput rotating posteriorly 
toward the sacrum. 

External version, when performed with ordinary skill and prudence, 
is a harmless procedure. Only inexcusable violence can rupture the 
membranes, separate the placenta, or injure the mother. There is no 
risk of infecting the mother, as the hand is not inserted within the 
birth-canal. This operation, however, is performed only by those 
familiar with palpation, who are accustomed to diagnosticate the position 



Fig. 405. 




External version. 



and presentation of the foetus by this method before labor begins. As 
the practice' of palpation becomes more general and is better performed, 
external version should be more frequently employed. 

Technique. For this manipulation the bladder and rectum should 
be empty. The patient is placed upon her back, her legs flexed upon the 



682 OBSTETRIC SURGERY. 

thighs, and the thighs upon the body. The abdomen is covered by one 
thickness of clothing only, beneath which the hands of the operator arc 
placed. The foetus iscarefully mapped oul l>\ percussion, supplemented 
by auscultation, and its position clearly defined. Jf* it is determined to 
completely turn the child, that portion which is to be brought toward 
the mother's diaphragm is gently pushed in that direction, while the 
other extremity of the foetal ovoid is carried toward the pelvic brim. 
(Fig. 405.) A series of gentle taps or pushes will best accomplish this 
purpose. Should this interference sel up uterine contractions, the ope- 
rator must hold the foetus in the position gained until the womb ceases 
to act. If suffering results, sufficient chloroform should be inhaled to 
annul pain. When the foetus is brought to its desired position it should 
be so held until the patient completely recovers from the anaesthetic, and 
it is evident that it will remain in this desired position. Should the first 
Btage of labor be nearly completed when external version is done, the 
membranes may be ruptured, when the presenting part will come into 
the pelvic brim and the foetus thus be fixed in the desired position. 
The descent of the child may be aided by suprapubic pressure, if neces- 
sary with the patient in Walcher's position. 

Where it is desired to perform external version to rectify an obliquity 
only of the foetus, this result is often attained most readily by carry ing 
the head gently upward in the uterus, and then pressing the vertex 
downward and backward within the pelvic brim. Walcher's position 
is often a useful adjunct to this manipulation. 

Where labor does not immediately follow 7 the performance of external 
version an effort may be made to retain the foetus in its desired position 
by bandaging pads upon each side of the uterus, or by applying com- 
presses in the long axis of the womb. It is often necessary to use 
heavy material, so that as much weight as can comfortably be borne 
should be present in the compresses so applied. It is rarely possible, 
however, to maintain the foetus for a considerable time in any position 
by this procedure, as the compression of the abdomen becomes painful 
to the patient, and unless labor comes on and the compresses are re- 
moved, the foetus may return to its former location. 

Combined Version. By combined version is understood the alteration 
of the position of the foetus by external and internal manipulation con- 
jointly : this is possible only when partial dilatation of the os and 
cervix is present, and when the patient is therefore in the first stage of 
labor. 

Indications. This procedure is indicated in cases where it is neces- 
sary to turn the child because of some danger which first becomes apparent 
when labor begins. In placenta praevia, for example, where the placenta 
is partially over the os, the first stage of labor may not proceed far before 
the physician discovers the complication which threatens. If the head 
is high in the pelvis and readily dislodged, he will naturally desire to 
bring the breech within the cervix, thereby compressing the placenta 
and preventing bleeding as birth proceeds. The writings of Braxton- 
Hicks and others have made this procedure familiar to physicians in 
the treatment of placenta praevia. In face presentation, in brow pres- 
entation, in cross positions, in prolapse of the cord when dilatation is 
but slightly advanced, combined version is often successfully employed. 



VERSION. 



683 



Technique. Strict antiseptic precautions are imperative in this pro- 
cedure. The bladder and rectum being emptied, a thorough vaginal douche 
of creolin (1 per cent.) or bichloride of mercury (1 : 5000) is given. The 
hands and arms of the operator are thoroughly scrubbed with soap and 
hot water, again in hot water, and then in bichloride solution (1 : 2000). 
It is usually unnecessary to employ a lubricant for the fingers ; but if 
such be used, it should be combined with an antiseptic ; creolin or lysol 
answers the purpose well. The patient is then brought to the edge of 
a bed or table, her legs and thighs flexed and suitably covered. The 
abdomen should be covered by one thickness of clothing only, so that 
the external hand of the operator may experience no difficulty. If the 
patient be excessively sensitive, chloroform may be employed ; if she is 
not easily made to suffer, no anaesthetic is required. Care should be 
taken not to rupture the membranes, as this version is most successful 
when all the amniotic liquid is present. The operator introduces suf- 
ficient of his hand within the vagina to enable him to pass two or three 
fingers through the cervix ; if this be done slowly and gently, pressing 
the pelvic floor downward and backward, but little resistance from the 



Fig. 406. 




Braxton Hicks's method of combined podalic version, first stage : one or two fingers of the left 
hand lift the head from the brim and push it toward the left iliac fossa, while the right hand 
pushes the breech transversely toward the right side. (Hicks.) 

levator ani muscle will be experienced. (Fig. 406.) While the fingers 
of the internal hand raise the part which presents at the pelvic brim, the 



684 OBSTETRIC SURGERY. 

other hand firs I carries this pari upward into the uterus, and then, press- 
ing alternately upon the further extremity of the foetus, gradually turns 
the child. When the child is made to present by the breech the 
operator endeavors, if possible, to bring the foetal legs within the pelvic 
brim before the breech descends. The internal hand is kept within the 
vagina until the version is complete, when it will grasp one foot of the 
♦•hild and draw ii gently downward through the cervix, causing the 
other thigh and breech to engage. A uoose of tape <»r bandage i> then 
passed over the ankle, and in this manner the presenting foot remains 
within the vagina. 

It is often advantageous, if possible, not to rupture the membranes 
until the leg presents at the pelvic brim, when the membranes may he 
broken and a foot readily grasped. If, however, the membranes have 
already broken, this version may still be accomplished unless the uterus 
be firmly contracted. 

Partial version by combined manipulation is often indicated. A 
beginning brow presentation, a presentation of the parietal bone, a 
beginning face ( presentation, or a partially posterior rotation of the occi- 
put, may often be corrected by this means. In these cases the internal 
hand carries the lowest point of the foetal head upward and backward, 
while the external hand, having located the vertex by palpation, en- 
deavors to bring it downward and forward within the pelvic brim. 
Walcher's position may be employed to advantage in these procedure-. 
If the membranes have not ruptured, they should be broken so soon as 
the head is favorably situated ; and should dilatation be tardy, it may 
be completed by artificial means. 

Advantages. Version by combined manipulation has many advan- 
tages. Under antiseptic precautions it exposes the mother to no great 
risk, if tetanus of the uterus be absent. It does no violence to the child, 
nor is there great danger by this procedure of prolapse of the cord or sep- 
aration of the placenta. It is impossible in complicated presentations of 
the foetus, when its limbs are wedged into the pelvis with the head or 
breech. Its successful performance requires patience and tact, and it 
has the disadvantage that it does not place the foetus so completely in 
the control of the operator as does internal version. Its use has been 
lessened in placenta praevia by the employment of the antiseptic tampon, 
while it is more frequently used to rectify malpositions of the head. 
In many of the latter cases the greater part of the hand is inserted 
within the vagina, the head grasped in this way and brought within the 
pelvic brim. 

Internal Version. By internal version we understand the turning of 
the child by the insertion of the hand of the obstetrician within the 
uterus : this is usually podalic version, because it is ordinarily desired 
in these cases to bring down the feet of the child. When the foetus has 
been so grasped by the obstetrician, it can readily be delivered, unless 
some important obstacle to birth exists in either foetus or pelvis. In- 
ternal version is, then, one of the most rapid and effectual methods in 
securing delivery. 

Indications. The choice of this operation will depend primarily upon 
the need existing for rapid delivery. As version, next to Csesarean sec- 
tion, is the quickest method of removing the foetus, the degree of neces- 



VERSION. 685 

sity existing for immediate delivery must largely determine the choice of 
the operation. Although the cervix must be nearly, if not completely, 
dilated to perform version successfully, still methods at our command 
for dilating the cervix are so efficient that a partially closed cervix need 
not prevent the choice of version. The comparison of version with 
symphysiotomy and forceps will be given later in this article, and for 
the present we will assume that the necessity for prompt delivery is 
present and that no insurmountable condition for the version exists. 
The obstetrician will readily recognize eclampsia, placenta praevia, 
threatened sudden maternal death, and prolapse of the cord, as indica- 
tions calling for prompt delivery. 

Method of Operating. As version is a radical operation requiring 
the introduction of the hand within the womb, it cannot be successfully un- 
dertaken without the employment of anaesthesia and the strict practice of 
antiseptic precautions. Chloroform is decidedly the better anaesthetic for 
version, as it successfully relaxes the uterus sufficiently to allow the neces- 
sary manipulations, while the rapid recovery of the patient from its influ- 
ence minimizes the risk of secondary relaxation and puerperal hemorrhage. 1 
Chloroform has also this advantage in version, that it may be conven- 
iently administered by the operator, alone, and version performed without 
skilled assistance. Winckel describes this procedure, and it is com- 
monly practised by those trained in Continental schools. Practitioners 
in the South and West also employ this expedient when without help. 

The administration of chloroform should always be done in a careful 
manner ; a simple device for giving the patient an abundance of air 
with the anaesthetic must always be used. The Esmarch mask is espe- 
cially convenient for this purpose. Failing this, the operator may pour 
a drachm or two of chloroform upon a handkerchief, and allow the 
patient to hold it in the hand and herself inhale the vapor. When she 
is sufficiently asleep, the hand will drop from the face, and version may 
then be begun. It is usually necessary, however, to continue the anaes- 
thetic until the version is completed, and hence the services of a skilled 
assistant are especially desirable. 

A most useful antiseptic for this operation is found in creolin, or 
lysol ; the advantage of this substance lies in its lubricant properties, 
whereby the employment of an ointment upon the hand is rendered 
unnecessary. Should the obstetrician be overtaken by an emergency 
and without an antiseptic, soap will be found most convenient and use- 
ful. Olive oil w r hich has been sterilized by heating may also be em- 
ployed. 

During the performance of version it may be necessary to pass a noose 
about one of the foetal limbs ; this is best made from soft bandage-material, 
thoroughly soaked in an antiseptic solution. 

As version must be followed in most cases by extraction, the operator 
should have forceps ready with which to deliver, if necessary, the after- 
coming head. As in cases requiring rapid extraction the birth-canal 
may be lacerated, suture-material and necessary instruments must be 
ready. Abundant hot water, for intra-uterine douching, and iodoform 
or bichloride gauze ought to be at hand. 

1 See recent writings by H. C. Wood and other therapeutists on the use of chloro- 
form. 



liMj 



OBSTETRIC SURGERY. 



To guard against .-hock and relaxation of the uterus, , ] gr. of strychnia 
should be dissolved and at band in a hypodermic syringe. The interests 
of the child must uo1 be forgotten in preparations for versiou and ex- 
traction. It is often horn asphyxiated, and hence hoi and cold water 
with a bath-tub, a hoi blanket, materials for iigating the cord, or 
haemostatic forceps for clamping it quickly, should be at hand. The 
child's life will he much safer if a skilled assistant he present, who can, 
if necessary, devote himself to it. 

The posture in which the patient shall lie during the performance of 
internal version varies in accordance with the usage of the operator and 
th» i circumstances of the case. American physicians commonly place 
the patient upon her hack in the lithotomy posture. When assistants 
are few, the thighs and legs may be held by passing a sheet beneath the 
knees and around the patient's neck. The abdominal surface should be 
easily accessible to the hand of the operator as version proceeds ; when 
without suitable help, many physicians do best by placing the patient 
upon her side, and anesthetizing her with a cone or mask held in one hand, 
while the other is inserted within the womb to grasp the foetus. The 
lateral posture in version has also the advantage of enabling the opera- 
tor to draw the foetus strongly downward and backward in the axis of 
the pelvic brim. The prone position for version has been advocated by 
Mensinga (Centralblatt fur Gynakologie, Xo. 23, 1896) ; he claims the 
following advantages for this procedure : the outlet of the pelvis is 
directed forward and upward, giving the operator much more room for 
the insertion of the hand ; the operator's hand and arm are also prone, 

Fig. 407. 

Rectum Os coceygis 




Version -with patient in prone position. (Mensinga.) 

affording a better use of the muscles and tactile sense. (Fig. 407.) This 
posture widens and partially dilates the uterus and vagina, and the con- 
traction-ring often disappears in these cases. There is less danger of 
bruising the soft parts. The patient has a pillow beneath the chest, and 
her head turned to one side, while the operator sits beside her, using 
either hand. Two dangers are considerably lessened, namely, tearing the 



VEESION. 



687 



uterus from the vagina and the occurrence of air-embolism. Patients 
suffer less pain when in this posture. Mensinga's paper upon the sub- 
ject has been criticised by Heuck (Centralblatt fur Gynakologie, No. 34, 
1896), who urges the employment of the lateral posture in version. 
Further clinical experience must decide the true value of the various 
postures in which operators have been accustomed to place their 
patients. As a rule, the dorsal lithotomy position will be most often 
employed. 

Preliminaries. Before the operator can intelligently proceed to perform 
internal version he must carefully map out the exact position of the foetus ; 
the bladder and rectum must be completely emptied, for a full bladder 
may greatly mask the position of the child, and an impacted bowel may 



Fig. 408. 




Eight dorso-anterior. (Farabetjf and Varnier.) 

offer a considerable obstacle to the descent of the foetus. Percussion 
and auscultation are often best performed when the patient is anaesthet- 
ized, as muscular rigidity is then removed. If the head be presenting 
above the brim of the pelvis, the feet and legs will be found on that 
side of the abdomen opposite from the greater portion of the head and 
in its upper quadrant. If the child be transverse, the back in front, 
the head upon the mother's left side, the right arm and shoulder pre- 
senting, the feet will be found upon the mother's right side in the right 
upper quadrant of the abdomen. (Fig. 408.) If the abdomen of the 
child be turned toward that of the mother, and its head upon her left 
side, the feet and legs will be found upon the mother's right side, usually 
below the umbilicus. If the head of the child be upon the mother's 



688 



OBSTETRIC SURGERY. 



right Bide, the back in fronl and the 1 < • it arm and shoulder presenting, 
the feel of the child will usually be found upon the mother's Lefil Bide, 
mid in the K't't upper quad rani of the abdomen. (Fig. 109.) If the 
head of tli<' foetus be upon the mother's right side, its abdomen directed 
toward thai of the mother, and the right arm and shoulder presenting, 
the feet and legs of the child will usually be found upon the left side 
of the mother, at or below the umbilicus. (Fig. HO.) In complicated 
presentations the legs may be completely extended, although the thighs 
are flexed upon the trunk. When the bead presents, the feet may be 
found just above the contraction-ring, if such has formed. A fool or 
leg is occasionally folded behind the back of the foetus, or the foetus 



Fig. 109. 




Left dorso-anterior. (Farabeuf and Varxier.) 

may present in neglected transverse presentations in the form of a 
wedge at the brim of the pelvis. In these cases an arm and shoulder, 
and occasionally a foot and leg, may present together. These complica- 
tions cannot always be distinguished by palpation ; as a rule, the gen- 
eral position of the foetus can be and should be ascertained by external 
examination before the version is undertaken. 

Choice of Hand. Much discussion has been elicited in deciding the 
question, which hand of the operator should be introduced in the per- 
formance of this operation : the natural usage of the obstetrician should 
be considered. Few persons have equal use and equal strength in both 
hands ; many will instinctively select the better hand for version. La 
Chapelle, Loviot, Charpentier and Pajot (Bulletin de la Societe obstStriccUe 



VERSION. 



689 



de Paris, No. 8, 1888) would use either hand, selecting that which seems 
most convenient for the operator. The choice of the hand will depend 
somewhat upon the posture of the patient : thus, if she be upon her 
back, the operator sitting in front of her, he will naturally select the 
hand opposite the feet. If the head be presenting, and the back of the 
child toward the mother's left, the left hand of the operator would seem 
most appropriate. If the child be with its head upon the mother's left 
side, the left hand again would be most nearly opposite the feet. If the 
patient be upon her left side, the operator will usually select the right 
hand for version j while if she were placed in the prone position, either 

Fig. 410. 




Right dorso-posterior. (Farabeuf and Varnier.) 

the right or left, in accordance with his individual peculiarity, would be 
chosen. Some have sought to formulate the rule that the hand should 
correspond to the side of the mother toward which the presenting part 
is directed, and while this may be correct in many cases, it is evidently 
not an inflexible law. Before introducing the hand the vagina should 
be thoroughly douched, preferably with creolin or lysol (1 per cent.). 
Both hands and forearms of the operator should be scrubbed with soap 
and hot water, again in hot water, and then in hot bichloride solution 
(1 : 2000) or in creolin solution (2 per cent.). The nails should be 

44 



690 



OBSTETRIC SURGERY. 



trimmed Bhoii and made smooth. Rings musl I x- removed. It having 
been ascertained thai dilatation is sufficiently advanced to admit the 
folded hand, the hand should be drawn into a cone-shape and its back, 
hut not the palmar Burface, anointed with creoliu or with an antiseptic 
ointment. The hand should then be introduced within the vagina with 
its greatesl axis of width parallel with the anteroposterior diameter of 
the vagina. The pelvic Hour should be carried gently downward and 
backward, gradually overcoming the resistance of the sphincter of the 
vagina and of the pelvic floor. The fingers should seek the os uteri, 

and by a gentle motion the hand should be carried through the OS and 
cervix and upon the foetal body. If the head be presenting, it should 

be gently pushed upward to one side, while the external hand, co-oper- 
ating with the internal, will assist in carrying the head out of the way. 
It" the shoulder be presenting and be found against the pelvic brim, 
care must be taken to dislodge it slowly and gently. The external 
hand may co-operate by making counter-pressure upon the fundus of 
the uterus, or by gently pushing the impacted part upward, while an 
assistant presses upon the womb. Should uterine contractions be severe, 
the operator should extend the hand upon the foetal body, and allow it 
to remain until the womb relaxes. Should the membranes have been 

Fig. 411. 




Grasping both feet. (Farabeuf and Varnier. 



found unruptured, they must, of course, be broken, when no time 
should be spent in pushing up the foetus, but the hand should be carried 
rapidly to the fundus of the uterus and the feet and legs grasped. The 
forearm of the operator will thus act as a plug, preventing loss of the 
entire amniotic liquid. 

Choice of Foot. Which foot shall be grasped in performing version, 



VERSION. 



691 



has been a question provoking much controversy. The exigencies of a 
given case must in some measure settle this question. Where version 
must be followed by rapid extraction, both feet, if possible, should be 
grasped. (Fig. 411.) Others urge that, in grasping a foot, it must be 
kept in mind that the back of the child should be brought anteriorly 
for its most successful extraction. Where the head is presenting and 
the back is to the left, the upper or right foot will best accomplish this 
end. In second positions of head presentation the left foot will be the 
better; in transverse positions, the back to the front, the lower foot 
should be grasped ; while in transverse positions, the abdomen to the 
front, the upper foot should be taken. (Fig. 412.) 

Niigel {Archivfur Gyndkologie, Band 44, Heft 1, 1893), from personal 



Fig. 412. 




Grasping the upper foot. (Farabettf and Varnier.) 



experience in thirty cases and from study of the literature, concludes 
that it is indifferent which foot is seized ; one should keep in mind the 
fact that the leg which is seized must be brought forward behind the 
symphysis, and that the performance of internal version requires more 
than the simple grasping of the leg and foot, but implies a gradual 
turning of the child's trunk so that the back shall come in front. In 
practice it is certainly inadvisable to waste time and effort in carefully 
selecting one or other foot. While the operator should carefully map 
out the foetus and decide which foot he chooses to make the version, he 
may find it almost impossible to discriminate when the four foetal limbs 
are found together, and he should then take the foot and leg most con- 
veniently grasped and rotate the foetus accordingly. None but the 
expert obstetrician will keep clearly in mind the precise mechanism of 
version in complicated cases, and hence practical considerations and not 



692 



OBSTETRIC SURGERY. 



theoretical rule- must govern us. The operator will best maintain hie 

grasp lipOD the leg and foot by taking the leg and ankle between his 

fingers, grasping the fool in the palm of the hand and folding the 
fingers and thumb over the foot. In this manner, his nails will be 

turned away from the wall of the litems, and he will do least damage 
in making traction. (Pig. 413.) 

Line Of Traction. It is of great importance in version that the ope- 
rator should make traction in the proper direetion. This should always 



Pig. n :;. 




Grasping the foot and making traction. (Farabeuf and Varnier.) 



be done in the axis of the pelvic brim, namely, downward and backward ; 
this necessitates a proper placing of the patient before the operation is 
begun, and must lead the operator to remember that obstetric operations, 
like those of surgery, are best done with the patient upon a suitable 
table. The average bed is too low and often too yielding to form a good 
support in operative cases. So soon as traction is begun upon the foot 
and leg, the external hand or the hands of an assistant should carry 
the opposite extremity of the foetus gently upward and backward in 



VERSION. 693 

the abdomen. By this combined manipulation the foetus is gradually 
turned, and the foot and leg brought within the vagina. Version is 
usually said to be complete when the foot presents at the vulva, and the 
head of the child has ascended to the fundus of the uterus. 

Precautions. Version is especially dangerous where the amniotic 
liquid has drained away and the uterus is in the spasmodic contraction 
known as uterine tetanus : the contraction-ring of Bandl will be found in 
these cases midway between the pubes and the umbilicus, while the head 
or shoulder remains in the lower uterine segment, which is excessively 
stretched. If this condition be pronounced, version is exceedingly dan- 
gerous, and many urge decapitation or craniotomy in these cases. If, 
however, the patient relaxes well under chloroform, and the contraction- 
ring be not strongly developed and high in the abdomen, it is often pos- 
sible, with care and patience, to complete version safely. Some have 
found advantage, in dislodging an impacted foetus, in placing the patient 
in the knee-chest posture ; but the operator's chief reliance in these cases 
must be upon complete anaesthesia and patience and manipulative skill. 
In dislodging impacted presentations no specific rule can be given. The 
lowest part presenting must first be carried backward, then upward and 
forward. The wedge which fills the pelvic brim can often be broken 
up by a slight change in the position of one of its component parts. 
If the elbow be presenting, it may be either carried upward into the 
uterus, or the arm drawn downward, and thus the lock be loosened. 
If the knee be presenting with the head, it is usually possible to move 
the head sufficiently to enable the operator to bring down the foot. 
Counter-pressure upon the fundus of the uterus is especially important 
in these cases to prevent tearing the womb from its attachment to the 
vagina. If the foetus be dead, embryotomy may be the much wiser 
procedure ; when the hand is inserted within the uterus the obstetrician 
should carefully palpate the presenting parts, and especially the head, 
to detect the presence of hydrocephalus or of a monstrosity. It would 
be evidently unwise to attempt version with marked hydrocephalus, as 
the large head of the child would almost surely tear the lower uterine 
segment. Under antiseptic precautions and anaesthesia the introduc- 
tion of the hand, if only for diagnosis, is so valuable a procedure that 
it should be employed, even if version be abandoned and some other 
procedure be determined upon. If a loop of cord be prolapsed, it 
should be grasped in the fingers and carried upward, if possible, above 
the brim of the pelvis, and placed at one or other sides of the promon- 
tory of the sacrum. The question of the life or death of the foetus is 
best determined by feeling the presence or absence of pulsation in its cord. 

The Completion of Delivery after Version. Although, tech- 
nically, version may be regarded as complete when the child has been 
turned within the womb, yet, in the exigencies of practice, the operator 
usually proceeds directly to complete the delivery. When version is 
cephalic, the head being brought to the brim of the pelvis, it is evident 
that further delivery is to be accomplished, if not spontaneously, by the 
use of forceps. Version, however, does not cause the head necessarily to 
engage, and without at least a partial engagement the forceps cannot 
be used : hence cephalic version must be followed by the adjustment of 
the foetal head to the pelvis. 



694 



OBSTETRIC SURGERY. 



To accomplish this, the operator must remember thai the oblique 
diameters of the pelvic brim are well considered the working diameters 
of the pelvis. He must further recall the facl thai the head will not 
engage unless flexion or complete extension is present ; of these, flexion 
i- always desirable and rarely impossible. When cephalic version is 
complete the operator should Introduce, under surgical anaesthesia! the 

entire hand within the vagina, and, palpating the head, should push up 
the chin of the foetus while his external hand by suprapubic pressure 
causes the occiput to descend ; this procedure should he done deliber- 
ately, hut thoroughly, the hand being retained within the cervix until 
at least a partial engagement of the head is assured. If the forceps 
is then ready, one blade may be passed along the internal hand before 
it is withdrawn, the other blade immediately following, and extraction 
may proceed forthwith. Should the operator find that extension has 
occurred, and that he cannot produce flexion without undue violence to 
the uterus, he is confronted with two alternatives : one, to make exten- 
sion complete, allowing the labor to proceed as a face presentation ; the 
other, to relax the uterine muscle by deep anaesthesia, to make podalic 
version, and immediate delivery. His choice of these alternatives must 

Fig. 414. 




Traction upon one leg. (Farabeuf and Vakniek. 



depend upon the degree of spasmodic contraction of the uterus which 
is present, the stage of descent of the foetal head, and the size of the 
child. Fortunately this condition is a rare one, and cephalic version 
usually leaves the head with the vertex presenting. 



VERSION. 



695 



In many cases the complete engagement of the head after cephalic 
version is greatly furthered by putting the patient in Walcher's posi- 
tion. In practising suprapubic pressure in these cases it is especially 
important that the bladder be completely emptied by catheter before 
this manipulation is undertaken. The further consideration of extrac- 
tion following cephalic version will properly be considered elsewhere. 

Extraction after podalic version may be rapid or deliberate, in accord- 
ance with the exigencies of the case. Where the placenta has become 
separated and active hemorrhage is going on, where the mother is in 



Fig. 415. 




Traction upon the thigh. 

* 



(Farabeuf and Varnier.) 



eclampsia, or where the mother has just died and the operator chooses 
version and extraction to remove the foetus, the child must necessarily 
be taken from the mother's body as rapidly as possible. This, of 
course, exposes it to great risk of death through asphyxia from pressure, 
prolapse of the cord, fracture of the cranium, fracture of the clavicle, 
or inspiration of blood and amniotic liquid. In performing rapid 
extraction, if the operator has brought down but one leg, he should pull 
strongly downward and backward upon this, the patient being upon the 
edge of a high table, until the second leg can be grasped. (Fig. 414.) If 






696 OBSTETRIC SUBQERY. 

the Beoond leg be extended upon the body of 1 1 » * - child, the child's trunk 
should be rotated into one of the oblique diameters of the pelvic brim, 
the fingers of the operator passed along the thigh upon its posterior 
Burfaoe, and an effort made to ilex it across the abdominal surface of 
the infant's trunk. Force applied near the knee-joint is usually most 
successful, as it flexes the leg and thigh in addition. (Fig. 415.) The 
leg and ankle can thus he brought within the grasp of the operator, and 

brought down. The fcatUS should he prevented from ascending into the 

uterus by a noose or bandage or tape passed about the ankle of the leg 
already secured. In rare eases, fracture of the femur occurs during this 
manipulation; hut if haste is imperative, this accident becomes of 
secondary importance. 

When both legs have been secured, the trunk of the fcetus should be 
rotated completely into an oblique diameter of the brim. Wrapping 
the thighs in a towel, the operator should grasp them firmly, making 
traction downward and backward, while his other hand should be laid 
broadly behind the pubes, carrying the head down within the pelvic 
brim and, if possible, maintaining partial flexion. So soon as the body 
has descended to the axillae strong traction downward and backward 
should be made upon the trunk, followed by raising the trunk strongly 
upward and outward, still maintaining it in an oblique position with 
regard to the mother's pelvis. This simple manoeuvre will usually 
bring the lower arm through the cervix and upon the pelvic floor. The 
hand of the operator, in grasping the legs, should then be passed along 
the child's back to the shoulder, and the lower arm brought down. 
Force should be applied at the humerus just above the condyles, as 
fracture is thus best avoided and flexion of the forearm secured. The 
operator must then quickly change hands, grasping the legs of the foetus 
with the other hand, and carrying the legs and pelvis of the child 
strongly upward and outward to the side opposite the shoulder which 
it is desired to bring down. The free hand passed along the back will 
usually be able to reach the arm without special difficulty. 

The foetus is thus extracted rapidly with but trifling injury. If 
strong traction has been made in this manoeuvre, accompanied by supra- 
pubic pressure by the operator or an assistant, the head will usually be 
found in one of the oblique diameters, and partially engaged. While 
there are several methods of extracting the aftercoming head, two are 
especially prompt and efficient ; in the first, the operator introduces the 
left hand with its palmar surface upward into the vagina, and places 
his longest and strongest finger within the mouth of the child. The 
first and third fingers rest upon the shoulders of the infant. The child 
lies astride his forearm. His other hand is laid broadly across the 
mother's abdomen just behind the pubes, and while strong traction is 
made by the hand which grasps the foetus, vigorous counter-pressure is 
performed by the external hand. It is rarely the case that the rapid 
extraction of the foetal head does not follow. 

When this manoeuvre fails no time should be lost in applying the 
forceps. If possible, it should be fitted to the sides of the child's 
head ; axis-traction should be used, the body of the child being held 
out of the way by an assistant. The head can usually be delivered by 
a few strong pulls. If difficulty is experienced in fitting the forceps 



VERSION. 697 

accurately to the sides of the head, Simpson's forceps, preferably, should 
be inserted at the sides of the pelvis, the head grasped in the best 
manner possible, and strong axis-traction made. Flexion will follow 
and delivery ensue. 

The rapid extraction of the foetus, if at full term, is rarely accom- 
plished without laceration to the mother. The cervix may be torn to 
its junction with the vagina, the pelvic floor lacerated, and the perineum 
ruptured. Nothing but danger to the mother's life would justify such 
a procedure, and the necessity for it is fortunately not common. If the 
mother's condition permits, these injuries should be at once repaired ; 
or, if complete suture is impossible, bleeding vessels in the cervix should 
be closed by suture, and a like precaution taken with tears of the pelvic 
floor and perineum. 

In cases of rapid extraction of the foetus after version the operator 
will usually find the placenta partially or wholly separated, and often 
closely following the child. In these cases the operator should invaria- 
bly remove the placenta as soon as possible, and assure himself, by the 
introduction of the entire hand within the uterus, that no clots or pieces 
of membrane are retained. The womb should be thoroughly douched 
with bichloride of mercury solution (1 : 8000), and tamponed with iodo- 
form gauze. This procedure takes but a few moments, and may pre- 
vent septic infection. So soon as the womb is empty, strychnia should 
be given (yg-th grain) by hypodermic injection, saline transfusion 
copiously added if needed, and appropriate treatment addressed to the 
condition of shock which may be present. It is often possible twenty- 
four hours after such a delivery to repair the cervix, pelvic floor, and 
perineum with chromicized catgut; this should be done, if possible, and 
good union is often obtained. 

While version and rapid extraction are sometimes indicated in many 
cases, the removal of the foetus should be performed very gradually. 
If, for example, the foetus be dead and the mother in no immediate 
danger, it is far better to consult her interests only, and to extract the 
child deliberately. 

The comparative mortality of rapid extraction or delay after version 
may well be estimated with reference to Dohrn's statistics (Zeitschrift 
fur Geburtshulfe und Gyndkologie, Band 14, Heft 1). In 903 transverse 
presentations, 23 foetal deaths resulted from premature loss of liquor 
amnii after intervals of several hours. Version was performed in most 
of these cases so soon as the internal os would admit the hand. By 
comparing the foetal mortality of spontaneous delivery in breech pres- 
entation with the mortality following version and extraction, he reaches 
the belief that extraction should be delayed so long as possible in the 
interests of the child. In 842 cases of spontaneous birth in breech 
presentation the foetal mortality was 49 per cent. In 5592 cases of 
version and extraction the foetal mortality was 57 per cent. In the 
artificial labor the coaptation of the foetus to the birth-canal is less 
perfect, and the child is much more exposed to injurious pressure ; hence 
the increased mortality. 

In cases of partial placenta praevia, when the mother is in fair con- 
dition and version has stopped the bleeding by compressing the placenta 
with the infant's body, delivery should not be rapid. The operator, 



698 OBSTETRIC SURGERY. 

having brought down the head into the pelvic brim and having applied 
forceps, should make gradual traction with regular intermissions, thus 
favoring dilatation of the parts and avoiding laceration, [f one leg has 
been secured and fastened by a noose, the operator may wait from fifteen 
minutes to a half-hour before making essential traction upon the body 
<>f the child. The uterus, meantime, should be stimulated to regular 
contraction, preferably by gentle massage and by the administration of 
alcohol, quinine, or coffee. Ether or chloroform inhaled in small 
amount- often serves as a stimulus to the continuation of labor. Espe- 
cial attention should he paid to maintaining flexion of the arms and head 
by suprapubic pressure, and if the child he followed down as it de- 
scends, the final delivery will be greatly expedited. The obstetrician 
should assi-t the child's descent by gentle traction, supplementing this 
by suprapubic pressure and uterine massage. When the hips of the 
child appear at the vulva, if the second leg has not descended, it should 
be unfolded and extracted. The legs should be wrapped in a warm 
towel, and gentle traction made upon both during the continuance of 
the labor. The manoeuvres for extracting the arms and gradual delivery 
are the same as those just described, with the exception that the opera- 
tor employs more deliberate manipulation, and by avoiding strong trac- 
tion on the trunk also avoids the danger of throwing the arms above 
the head. 

When the head of the child reaches the pelvic floor it must, of 
course, be promptly extracted; the mother, being in fair condition, will 
aid materially in this procedure by closing her lips tightly and strongly 
bearing down. In uncomplicated cases, if the thighs and trunk of the 
child be bent strongly upw r ard and backward toward the mother's 
abdomen, and if the operator makes strong suprapubic pressure down- 
ward and backward, the mother co-operating by bearing down strongly, 
the head will readily be born. Should the mother's pain become so 
severe as to paralyze her efforts, the rapid inhalation of chloroform will 
usually obviate this trouble. Occasionally, the levator ani muscle con- 
tracts so strongly when the head reaches the pelvic floor that the head 
is retained firmly, and great difficulty is experienced in efforts to deliver. 
The prompt use of chloroform completely removes this obstacle. 

If the mother is in good condition after the delivery of the child, the 
placenta not having been separated and bleeding being absent, there 
need be no haste in removing the placenta. The obstetrician may wait 
fifteen to twenty minutes, encouraging the mother, when she has had a 
brief rest, to bear down and thus to separate and expel the placenta 
spontaneously. Should, however, this effort fail, the after-birth must 
be artificially delivered, and the uterus thoroughly emptied as already 
described. Gradual delivery after version is accompanied by little 
shock. In many cases the patient seems less fatigued than after a tedi- 
ous spontaneous delivery. Lacerations are often less in frequency and 
extent, because time is given for the gradual dilatation of the birth- 
canal ; hence no extensive repair is needed in these cases, and lacera- 
tions are usually inconsiderable in extent. 

While the life of the child is often lost in both rapid and gradual 
extraction after version, still in many cases the infant can be revived, 
although born asphyxiated. This is especially the case when the child 



VERSION. 699 

is not large in size, the birth-canal not firm and resisting, when bleeding 
has not occurred, and when the cranium and thorax have not been 
exposed to severe pressure. An effort should invariably be made to 
resuscitate the infant, and such will often prove successful. 

The Complications of Version. It is evident that various conditions 
of the mother may seriously complicate the performance of version. 
AVe shall speak of contracted pelvis later in this article, in connection 
with the choice of the operation. There are, however, other conditions 
which may be present, which may render version impossible or seriously 
complicate its performance. 

The constant danger and oftentimes complications of version lie in 
rupture of the uterus, or tearing of the vagina from its attachment 
to the womb. Obstetricians, with Zweifel, Yeit, and van der Mey 
(Jlonatschrift fur Geburtshulfe unci Gynclhologie, Band 1, Heft 2, 1895), 
agree in condemning version when uterine rupture threatens, and in 
urging embryotomy or Cesarean section. It is occasionally possible 
where rupture of the uterus follows version to rescue the patient by 
ccelio-hysterectomy, as in a case reported by Arndt (Centralblatt fur 
Gynclhologie, No. 24, 1896). In this patient version was performed 
one and a half hours after rupture of the membranes, by a skilled 
operator, and without apparent difficulty. The uterus, however, had 
been torn from its attachment to the vagina. When, however, the 
uterus has ruptured before an attempt at delivery has been made, ver- 
sion is indicated only when the rent in the womb is a small one, when 
but a small part of the foetus has escaped, when but little bleeding has 
occurred, and when the womb is not tightly contracted upon the child. 
In thirty-one cases of uterine rupture version was performed in four. 

The worst complications of version are found in patients in whom 
the operation has been badly chosen, some insurmountable obstacle to 
delivery having been overlooked. It is almost impossible in such cases 
to avoid severe injury to the mother : thus, Pinzani (Ann. cli Ostetr. e 
GinecoL, Xo. 12, 1894) reports the case of a woman who had severe 
pelvic deformity, on whom internal version had been unsuccessfully 
tried, the operator bringing down a foot and hand. Complete rupture 
of the urethra and part of the posterior wall of the bladder had re- 
sulted. Although the patient was delivered by the Cesarean opera- 
tion, she died of pyaemia on the seventeenth day. A somewhat similar 
case is reported by Routh (British Medical Journal, Xo. 1695, 1893); 
this patient had been delivered by version by the house physician of a 
maternity hospital : hemorrhage and collapse followed. On examina- 
tion the vagina and uterine segment were badly torn, the umbilical 
cord prolapsing through the rent. The patient died from pyaemia. 
Lohlein (Deutsche meclicinische Woehenschrift, Xo. 19, 1896) reports the 
case of a patient who died after her third confinement, her first having 
been terminated by embryotomy, and the second by symphysiotomy. 
In the third labor an attempt was made to deliver by version and ex- 
traction, which resulted in serious laceration of the cervix, lower uterine 
segment, and vagina, with death from hemorrhage. Occasionally, rupt- 
ure of the uterus during version is followed by recovery. Treu (St. 
Petersburger meclicinische Woehenschrift, Xo. 47, 1894) describes the 
case of a multigravida whose child died within the womb, and in whom 



700 OBSTETRIC SURGERY. 

it was accessary to extracl the dead foetus by version ; the lower portion 
of the uterus was bound down by an old adhesion extending across the 
posterior Burface of the lower uterine segment. The lower segment 
ruptured just above this adhesion: the foetus and placenta, however, 
were removed without especial difficulty, the patient making a good 
recovery. These cases are sufficient to indicate the dangerous complica- 
tions oi version In improper cases. 

Certain abnormalities in the position of the foetus contraindicate 
version; thus, in ectopic gestation where the child has developed after 
the escape of the embryo from the tube. Fenger, in a paper read before 
the Chicago Gynecological Society, Dec. 19, 1890, warns against the 
performance of version after the foetal sac has been opened, because the 
sac-walls are so thin that they will rupture during the manipulation. 
He cites the cases of Santini and Bandl, both of which resulted fatally. 
Occasionally, double version is required in twin pregnancy. Loviot 
(Annates des Gynieologie et cV Obstetrique, June, 1892) reports two cases 
of twin pregnancy in which transverse presentations or anomalous pres- 
entations of the foetus required the performance of double version. 
Rcesger (Centralblatt fur Gi/ndkologie, No. 22, 1890) describes the case 
of a multipara in whom the uterus was greatly distended ; both children 
presented in transverse presentation in separate foetal sacs : each was 
delivered by version. 

Unusual Complications. Complex presentations in the foetus often 
embarrass the operator greatly in the performance of version ; a 
shoulder and smaller foetal parts may become so impacted in the 
pelvic brim as to constitute a wedge, resisting all efforts at sponta- 
neous expulsion. In these cases the wedge must be broken up before 
delivery can occur in any manner. If the child be dead, embryotomy 
may prove the more advisable procedure ; but if the child be living, 
the patient should be thoroughly anaesthetized with chloroform, the 
hand introduced gently, and the foetus sufficiently moved from its posi- 
tion to enable the smaller parts to be pushed out of the pelvic brim and 
version to be performed. It is only by the exercise of the utmost 
patience, with considerable strength and dexterity, that this procedure 
can be successfully employed. The hand, however, is the safest instru- 
ment for this purpose, as it appreciates the resistance of the uterus and 
also any gain which may happen through decomposition of the wedge. 
Should such an effort not succeed, abdominal section will often prove 
the safest method of delivery. It is occasionally observed that the con- 
traction-ring when strongly developed may resist the movements of the 
foetal shoulder ; thus, Helme describes a case (British Medical Journal, 
No. 1589, 1891) in which the contraction-ring successfully resisted all 
movement of the foetal shoulder. The prolapsed arm was finally pulled 
down and the foetus pushed upward into the uterine cavity, when ver- 
sion was readily accomplished. 

Brow presentation has been considered by some as an indication for 
version. When, however, the head of the child is firmly compressed 
at the pelvic brim, Vallois (Archives de Tocologie, No. 8, 1894) would 
avoid version because of the danger of uterine rupture, and would per- 
form symphysiotomy instead. It is considered in these cases that the 
impaction of the head is so well marked that any effort to dislodge it 



VERSION. 701 

must result in serious injury. In dorso-posterior positions of the foetus 
version sometimes fails; thus Zweifel (Centralblatt fur Gynakologie, No. 
20, 1895) reports a case in which he failed in version, and ended labor 
by decapitation. Sanger, in. 1892, described a case of dorso-posterior 
position in which traction was made upon the upper foot, the arm 
having prolapsed ; the result was impaction of the foetus and rupture 
of the uterus. In these cases Zweifel urges the operator not to pull 
upon the upper foot of the child ; if the arms have prolapsed, they 
should be let alone and either foot grasped, and traction made strongly 
downward and backward toward the sacrum. 

Cephalic version may be rendered impossible by coiling of the 
umbilical cord about the foetus ; thus, Budin reports one case in which 
the cord Avas about the trunk and beneath the axillse ; it was cautiously 
dislodged and labor proceeded spontaneously. Defour reports two 
cases in which cephalic version was prevented by the cord about the 
neck {Archives de Tocologie, No. 1, 1889). When ordinary manipu- 
lation fails, the foetal body must be carefully palpated to determine the 
presence of such a complication. 

Version after Abnormal Fixation of the Uterus. Recent methods 
of fixing the uterus by operative procedure have given rise to interest- 
ing complications in subsequent pregnancies. Experience has shown 
that, in cases of vaginal fixation of the uterus, the foetus oftentimes 
assumes abnormal positions by reason of the abnormal condition of 
the womb which renders version necessary. In Milander's report of 
these cases (Zeitsehrift fur Geburtshulfe und Gynakologie, Band 33, page 
464), a case of delivery by version after ventrofixation is described 
by Frommel ; Gubaroff performed Cesarean section on a primipara 
who four years previously had a ventrofixation performed by Kiistner : 
in this patient two unsuccessful attempts were made to perform version. 
Milander also performed version in a case of cross-birth, the back pos- 
terior, occurring after ventrofixation. Podalic version and slow extrac- 
tion delivered a living child. In seventy-four women Avho had ventro- 
fixation and who became pregnant, three cross-births required version. 
It is evident that any form of ventrofixation which fastens the uterus 
by a broad, firm band of adhesion predisposes to great dilatation of the 
posterior wall of the uterus during pregnancy, and to malpositions of 
the foetus, necessitating version. In operating upon these cases great 
caution and patience are necessary. Strassmann (Arehiv fur Gynakolo- 
gie, Band 1, Heft 3, 1896) considers version indicated early in labor in 
patients who have had vaginal fixation of the uterus. Wertheim {Cen- 
tralblatt fur Gynakologie, No. 2, 1897), in thirty-seven patients operated 
upon by vaginal fixation, had three who subsequently became pregnant. 
In one of these cases the posterior wall of the uterus was stretched so 
excessively that version was performed early. After the foot had been 
brought down, a weight was attached to it and the further expulsion 
left to nature : three hours after, a living child was born. In some of 
these cases, after version uterine relaxation and hemorrhage have been 
reported, which greatly complicated the mother's recovery. In a thesis 
published in Berlin, in 1896, Duhrssen reports a case of vaginal Csesa- 
rean section in a patient who had vaginal fixation of the uterus and 
could not be spontaneously delivered. His operation consisted in open- 



702 OBSTETRIC SURGERY. 

ing tlu* vault of the vagina and uterus, and performing version and 
extraction: mother and child recovered. 

Version lnd Symphysiotomy. A.s symphysiotomy is successful 
in enlarging the pelvis, it would seem thai in a pelvis thus made larger 
version might meet with decided success. On the other hand, injury 
to the vagina] walls may readily happen after symphysiotomy, if the 
soft part- are brought strongly upward against the cut ends of the 
pubic bones, and hence version, which puts the birth-canal upon the 
stretch, might readily result in injury after symphysiotomy. There are, 
however, a considerable number of cases on record in which symphysi- 
otomy has been followed by version and extraction. Thus, Garrigues 
(American Journal of the M<<li<-<il Sciences, March, 1893), after sym- 
physiotomy performed version, extracting the head of a full-term male 
foetus with considerable difficulty. Mother and child recovered. Sym- 
physiotomy in some cases may follow version when it is apparent that 
the pelvis is too small to permit successful extraction. Thus, Braun 
(Gentralblatt fur Ghjndkologie, No. 26,1893) reports a case of trans- 
verse presentation in a patient whose children had previously died at 
birth, in which version was first performed. As delivery proved impos- 
sible, symphysiotomy w r as then resorted to, followed by extraction. 
One of the sacro-iliac joints was slightly injured during the delivery. 
Mother and child made a good recovery. In the Mbnatschrift fur 
Geburtshiilfe, Band 2, Heft 2, 1895, Spaeth describes a case in which he 
succeeded after symphysiotomy in delivering a living child by version 
when axis-traction forceps failed. From the study of statistics, he finds 
that symphysiotomy and version have a mortality of 9j 5 y- per cent, to 
mother and child, Avhile symphysiotomy and forceps give a death-rate 
of 11 per cent, for the mother, and 21 per cent, for the child. In 
Pinard's report of his symphysiotomies for 1895 (Annates des Gyne- 
cologies Jan., 1896) we find the conclusion that when the head remains 
high after symphysiotomy version is better than forceps, but that when 
the head descends into the pelvis so soon as the pubic joint is open, that 
the forceps should be chosen in preference to symphysiotomy. In 
twenty symphysiotomies, version Avas done in three cases in which for- 
ceps failed to extract. 

Version and Forceps. It is most natural to compare version with 
the use of forceps, as the two operations are constantly presenting them- 
selves for the practical choice of the obstetrician. Our former grounds 
of selection in these cases were largely based upon the conception com- 
monly held of the results of forceps-pressure upon the foetal head. It 
was formerly taught that, if the forceps was applied over the face and 
occiput, bulging of the parietal diameter occurred, considerably increas- 
ing the measurements of the head in this direction. Aside from the 
possible injury to the face following application of forceps to face and 
occiput, it was commonly believed that the procedure was useless, espe- 
cially in contracted pelves. The investigations of Milne Murray 
(British Medical Journal, No. 1870, 1896) tend to show the fallacy of 
this belief. He has demonstrated by experiment that the occipito- 
frontal diameter of the head may be compressed from one to one and a 
half inches without increasing the biparietal. The various segments 
of the cranium slide under one another, and thus a vertical, and not 



VERSION. 703 

a transverse, expansion results. In flattened pelves, where version was 
formerly thought to be clearly indicated, Murray urges the application 
of forceps ; he asserts that he has delivered living children where the 
antero-posterior pelvic diameter of the mother's pelvis w T as three and a 
quarter inches, and even two and three-quarters inches. In these cases, 
so soon as the head passes the promontory of the sacrum, the forceps 
and head naturally rotate into the posterior extremity of one of the 
oblique diameters, and the head descends in this diameter through the 
pelvic cavity. Frank (Monatschrift fur Geburtshillfe, Band 3, Heft 1, 
1896) would not apply forceps unless the greatest circumference of the 
foetal head was already Avithin the pelvis. He urges the advantages of 
version in these cases ; and when version cannot succeed, he would 
resort to craniotomy. 

In the Zeitschrift fur Gyndkologie, Band 24, Heft 2, 1896, Schultz 
reports a series of cases in which he chose the forceps instead of ver- 
sion. This embraces contracted pelves, primiparous labor, threatened 
uterine rupture, and prolapse of the cord. He would perform version 
when an indication for the immediate termination of labor arose. 
When the amniotic liquid has long since escaped he considers version 
preferable. He would choose forceps, however, in slightly contracted 
pelves when the os and cervix are well dilated. In contracted pelves 
of high degree forceps should be applied as a tentative measure only, 
and with great caution. He thinks the use of forceps an easier opera- 
tion than version, and considers the result generally better for the 
mother and child. 

Version in Contracted Pelves. In flat pelves version has long held 
the favorite place among methods of delivery. It has been urged that 
after version the fcetal head is brought transversely through the pelvic 
brim, thus offering its bitemporal diameter, which is a small one, to the 
contracted antero-posterior diameter of the brim of the pelvis. In 
these cases the occiput would fit into the space at the side of the sacrum, 
and thus the head would pass through a considerably flattened pelvis. 
This view, however, must be modified somewhat in the light of recent 
researches, already quoted, upon the action of forceps when applied to 
the occipitofrontal diameter of the head. There is no question, how- 
ever, that in many cases of contracted pelvis where the degree of nar- 
rowing is a moderate one, and especially where flattening of the pelvis 
is present, that version presents a most efficient method of delivery. 
Thus, Hausen (Hospital- Tidends, Sept. 9, 1891) reports three cases of 
version in contracted pelves in women who had previously had difficult 
births. Two of these were flat, not rhachitic, pelves, but slightly con- 
tracted ; the third was a flat, rhachitic pelvis. The children were at 
term, and both mothers and children recovered. Version was per- 
formed under chloroform in these cases, and the patient's uterine con- 
tractions were excited by allowing her to come partly from the anaes- 
thetic after version was completed. Scharlan and Strassmann (Zeitschrift 
fur Geburtshulfe, Band 29, 1894) write concerning version in contracted 
pelves. The former would choose this operation in moderately con- 
tracted pelves, and in those in which the true conjugate was 7-| cm. 
Strassmann urges the difficulty which sometimes arises in bringing the 
after-coming head through a moderately contracted pelvis. 



704 OBSTETRIC SURGERY. 

Id general, modern teaching upon the subject of version in contracted 
pelves may be Bummed up as follows : in simple, flat pelves of moderate 
contraction version is exceedingly successful. In symmetrically con- 
tracted pelves of moderate contraction every effort should be made to 
induce the head to engage, when Walehers position and the use of 
forceps will usually deliver the patient. In all considerable degrees 

of pelvic deformity Csesarean section should be chosen, and version 
avoided. 

There are some who assert that an unfavorable position of the fetal 
occiput justifies the obstetrician in the performance of version ; chief 
among these is Grandin, whose writings upon the subject in his Text- 
Book are familiar. There is no question that one skilled in version can 
thus terminate promptly and with good success a labor which otherwise 
would be tedious and possibly dangerous to mother and child. Those, 
however, not accustomed to the practice of version would do well to 
secure, if possible, anterior rotation of the occiput by manual rectifica- 
tion, completing labor by the application of forceps. 

Version or Symphysiotomy. In cases of moderately contracted 
pelvis the interesting question often arises, Shall labor be allowed to 
proceed until the membranes have ruptured and labor-pains have had an 
opportunity to bring about engagement of the head or spontaneous birth, 
or shall delay be obviated by the prompt performance of version before 
the membranes rupture, and so soon as dilatation is complete? In view 
of the success of symphysiotomy, the choice in some cases becomes a 
matter of considerable difficulty. Wehle (Miinchener medicinische 
Wochenschrift, No. 25, 1894) had an unusual opportunity for comparing 
the two procedures. Two cases of flat, rhachitic pelves were admitted 
to the Dresden clinic within a few hours of each other; the first had 
an internal conjugate of 7 cm., the second of 6 t 5 q cm. In the first, 
version and extraction were practised ; in the second, symphysiotomy. 
Both mothers and both children recovered. The version was made so 
soon as the os was dilated, and before the membranes had ruptured. 
The patient was placed in Walcher's position, and a child weighing 
3780 grammes was rapidly extracted. The mother was discharged 
convalescent in ten days. 

In the second case the symphysiotomy proceeded without complica- 
tions, and the after-treatment was entirely successful ; four weeks, how- 
ever, were consumed in the patient's recovery. 

In the same journal Bushbeck reports the general results of nine 
symphysiotomies performed during two years in the Dresden clinic 
among a total of 3210 confinements : it is, however, Leopold's teaching 
that in pelves having a true conjugate of 7 cm., in flat, rhachitic pelves, 
with 7^ cm. true conjugate, and in justo-minor pelves, that version so 
soon as the os is dilated and before the membranes rupture gives best 
results for mother and child. 

Olshausen (Centralblatt fur Gynakologie, No. 36, 1894) criticises the 
stand taken by Leopold, and calls attention to the fact that it is in 
many cases impossible to assert that spontaneous birth cannot occur 
unless the operator delays until after the membranes have ruptured 
before he interferes. If such delay be practised, it is evident that ver- 
sion is not so applicable as symphysiotomy. When the amniotic liquid 



VERSION. 705 

has largely escaped version is attended with more difficulty and 
violence to the mother than is symphysiotomy usually ; hence, unless 
the operator is positive, judging from the shape of the pelvis and esti- 
mating as well as possible the contour and size of the head that version 
will be successful, it is the part of wisdom to wait until the membranes 
rupture and the patient has had several strong pains before submitting 
her to interference. On the other hand, there are many operators 
especially proficient in version who can unquestionably do better by 
performing this operation in all possible cases. 

In making a practical choice of these two procedures, it must be 
remembered that, under antiseptic precautions, the maternal mortality 
of version is very little ; the foetal mortality, however, is considerable. 
On the other hand, symphysiotomy is a child-saving operation, which, 
however, exposes the mother in some cases to considerable risk. When 
the conditions are all favorable for version there can be no question of 
the fact that this procedure can be carried out more successfully by one 
individual without skilled assistance or with but limited help, than any 
other obstetric operation. If necessary, the operator can anaesthetize 
his patient himself and perform the version: this is the reverse of what 
is true in symphysiotomy, where several assistants are required, and 
where full antiseptic precautions are necessary. 

Again, if version be not attempted, if the head can be brought just 
within the pelvic brim, it may be possible to secure delivery by the use 
of forceps in combination with Walcher's position. Should forceps 
fail, however, symphysiotomy can readily be performed. This is espe- 
cially well illustrated in Pinard's cases in the French clinics, where it 
is customary to apply forceps, and if descent of the head does not 
follow, to perform symphysiotomy without removing the forceps. The 
after-treatment, however, of symphysiotomy is so prolonged and labor- 
ious that the operation must be confined to cases where good nursing is 
available for a considerable length of time. In comparing the two pro- 
cedures, version still remains the most prompt, simple, and efficient 
treatment, capable of fulfilment by a single skilled person, among the 
resources of the obstetrician. Version is especially appreciated by 
physicians who practise where assistants are difficult to obtain, and who 
are familiar with the use of chloroform in various obstetric manipula- 
tions. 

The Frequency of Version and its Results. Among the most interest- 
ing of the many questions relating to version is the choice of the opera- 
tion in view of the success of modern Cesarean section and the induc- 
tion of labor. Modern writers having extensive clinical observation 
publish from time to time results of groups of cases, from which the 
field of version in comparison with other operations may be determined. 
In Leopold's book upon Cesarean section (Der Kaiserschnitb unci Seine 
Stellung zur Kunstlichen Fruhgeburt Wenching unci Perforation bei Engem 
Becken, Stuttgart, Enke, 1888) are reported 45 cases of induced labor 
in contracted pelves, with but one death, and that from sepsis ; 71 
craniotomies are reported, with no maternal mortality from sepsis ; 107 
versions are also reported, with septic mortality of nil. The mortality 
after Csesarean section is stated to have been at Dresden 8^- per cent., 
of which 4^- per cent, was from sepsis. A similar book has been issued 



706 OBSTETRIC SURGERY. 

by Braun and Herzfeld, of Vienna {Der KaiserschniU und Seine Shi- 
lling \ur Kv/nstliohen ¥\rukgeburt y Wendv/ng y Atypiachen Zangenoperatwn f 
Oraniotomie wnd zu den Spontanea Geburten oei Engen Becken. Wien, 
1888), in which are given the results collected in 2<>o7 labors; among 
these patients, III had contracted pelves: the frequency of the differ- 
ent operations Is shown by statistics appended. Induced labor was per- 
formed 54 times in 2:},!)1I eases: all of the mothers recovered without 
essentia] rise of temperature: of the children, 35, or 73 per cent., were 
horn living. Version and extraction were performed 89 times in con- 
tracted pelves in 20,607 labors. Results of version were 2 maternal 
deaths, and, as regards the child, 55 children born living and 34 dead ; 
and deducting cases in which the foetus was dead before version was 
performed, we have 75 infants, of whom 55 were born alive and 20 
were dead. Curiously enough, among these eases there were 78 atyp- 
ical forceps-deliveries for contracted pelves, and of these, one died of 
sepsis. In craniotomy, 56 cases were so treated, 5 of the mothers 
dying. It is of especial interest to note the results of natural, spontaneous 
labor in contracted pelves ; this occurred 163 times in 20,607 births, 
and among these but 3 children were stillborn. The results of various 
forms of Csesarean section showed, first, a mortality of 41^- per cent. ; 
this result was afterward improved greatly by the perfection of hys- 
terectomy. 

From the Rotunda we obtain the report of Smyly, the master of the 
Hospital (Dublin Journal of Medical Sciences, July, 1893), in which are 
reported 3602 labors, and among them version was performed in 25 
cases. Ross, of Toronto (American Journal of Obstetrics, 1895), in his 
analysis of 6777 cases of confinement, reports 45 versions, in 19 of 
which the child was saved, and in 26 it was lost. 

During the late Congress at Geneva a report was rendered concern- 
ing the frequency of various forms of contracted pelves in different 
countries, and also the treatment followed by various operators in deal- 
ing with these cases (Monatschrift fur Geburtshulfe und Gynahologie, 
Band 4, Heft 5, 1896). Barnes, of London, in 38,065 cases of labor, 
found 150 flat pelves, and 45 otherwise deformed ; among these 
patients version was done 74 times. Pestalozza, of Florence, among 
7962 pregnant patients, observed 2437 in which the pelvis was slightly 
altered ; 38 versions were done among these cases. One of these oper- 
ations resulted in rupture of the uterus, and death. In the Annates de 
Gynecologic, August, 1895, Gueniot reports his observations in 60 con- 
tracted pelves. Cephalic version -was performed twice, forceps and 
version once, and podalic version once. Massen (Annates de Gyne- 
cologic, September, 1894), in 2061 labors, reports 16 versions made be- 
fore labor was fully advanced and by choice. In 3 of these the pelvis 
was contracted, its oblique conjugate measuring 10 t 4 q cm., and in 9 cases 
the conjugate varied from 10 T 5 g- to 9 cm., while in 3 cases it ranged 
behveen 9 and 7 cm. Fourteen children were born living, and 2 as- 
phyxiated. None of the women died, although some had rise of tem- 
perature. 

In a paper upon the " Treatment of Cancer of the Uterus during 
Pregnancy/' Theilhaber (Archiv fur Gynnkologie, Band 47, Heft 1, 
1894) has collected 5 cases of pregnancy complicated with cancer of 



VERSION. 707 

the womb, in which version was performed at the end of the pregnancy. 
In only one did mother and child recover ; in three, both mother and 
child died ; in one, the mother lived and the child perished. 

In neglected cases we occasionally observe a species of spontaneous 
version, which is often spoken of as " spontaneous evolution." The 
foetus being in transverse presentation and the shoulder impacted, con- 
tinued pressure from uterine contractions doubles the trunk of the 
child laterally in a very strong manner, gradually forcing down the 
breech and thighs until version is performed. In other cases one 
shoulder is first born, then the other, then the chest and breech, and 
finally the legs. Ordinarily, one would expect that such delivery might 
be possible where the child is small, the mother's uterine contractions 
vigorous, and the birth-canal very dilatable. In some cases slight pel- 
vic contraction is present; thus, Grasemann (Centralblatt fur Gynako- 
logie, No. 43, 1895) reports the case of a slender primipara with 
slightly flattened pelvis, in which the foetus lay transversely, the back 
posteriorly, the right arm having been forced downward into the 
vagina. The shoulder was wedged into the pelvis. The chest of the 
child was deep in the pelvis. The head and the breech had been forced 
upward. The patient's pains were so strong that uterine rupture was 
threatened. While preparing to perform embryotomy, the right 
shoulder was observed to be forced downward and gradually expelled, 
followed by the birth of the left arm and shoulder, then the chest and 
breech, and finally the legs. The physician in attendance readily 
delivered the head. The pelvic floor was uninjured : the child had 
but recently died, and was at full term and of average size; the 
patient recovered. 



CHAPTER XXXIII. 

EMBRYOTOMY. 

By embryotomy is understood a reduction in the size of the foetus by 
cutting or crushing any portion of the foetal body. As the head of the 
child commonly presents, and as it usually offers the greatest obstacle to 

delivery, some cutting or crushing operation upon the cranium, called 
craniotomy, is mosl frequently performed. Embryotomy is one of the 
oldest of obstetric operations, and its abuse led to remonstrance on the 
part of religious authorities and to the prohibition by some churches of 
the performance of this operation upon the living child. The improvement 
in obstetric surgery has gradually diminished the frequency of embry- 
otomy and greatly narrowed its field. It remains, however, a proper 
procedure in certain cases, and one which, addressed to the interests of 
the mother only, may often serve a most useful purpose. 

Embryotomy is sometimes performed unwittingly by the use of for- 
ceps. A physician who has no knowledge of pelvimetry, and is there- 
fore ignorant of the size of the pelvis in a case which he is attending, 
may find the head presenting, the parietal bone being lowest at the 
pelvic brim ; and, mistaking this condition for engagement, he may 
apply the forceps and by strong traction endeavor to deliver ; he will 
not succeed, however, in such a case, but will bruise and fracture the 
cranium, destroying the life of the child : this is craniotomy, although 
not a deliberate and premeditated embryotomy. Again, the head of 
a child may be 'born, and unusual size of the shoulders may prevent 
further delivery. Efforts to bring down the shoulders may result in 
fracture of the clavicle on one or both sides ; this may also be styled 
embryotomy, although not deliberately chosen. 

Indications. In the present state of obstetric surgery embryotomy is 
clearly indicated in but two conditions : first, when a foetus larger than 
the birth-canal is dead when the physician first sees the case ; and, sec- 
ond, when the presence of a monstrosity is diagnosticated. In either of 
these events embryotomy is clearly indicated. When a living and un- 
injured child is contained within the womb of a patient whose pelvis is 
too small to permit normal birth, embryotomy is contraindicated, and 
some other obstetric operation which offers a reasonable chance of sav- 
ing the child's life must be selected. 

While such is the duty of the modern obstetrician, he may at times 
be placed in circumstances where he is not at liberty to follow strictly 
such a line of procedure. As in the time of Napoleon, so at the pres- 
ent day the law prevails that the interests of the mother must always 
take precedence during confinement. Exactly how far she is at liberty 
to choose to sacrifice the life of her foetus is a question difficult to deter- 
mine. Another complicating factor lies in the very differing conditions 
under which physicians are placed in their various fields of practice : 

(708) 



EMBRYOTOMY. 709 

thus, an obstetrician residing in a city may decline to perform embry- 
otomy upon a living child, knowing well that some other legally quali- 
fied practitioner can always be found without difficulty who will 
undertake the operation. He may properly transfer the case, if he so 
desires, to some one else. On the contrary, the physician who practises 
outside of cities may find himself alone in the presence of a complicated 
confinement where an obstetric operation is demanded to save the lives 
of mother and child. The parents and friends may decline this opera- 
tion, and insist upon embryotomy. If no physician but himself is 
available, and the mother's interests are clearly in danger, he must, 
under remonstrance, yield to his patient, if he cannot obtain her con- 
sent to follow his judgment. It has been proposed by some that the 
physician should delay the case until the child has died from prolonged 
birth-pressure, when he may perform embryotomy without compunc- 
tions : this procedure is so dishonest to the interests of mother and 
child that it is unworthy the attention of reputable men. The rights 
of the foetus should be distinctly protected by the medical practitioner. 

In securing the consent of the patient and her family to perform 
some life-saving operation instead of embryotomy, the practitioner at 
times can procure considerable aid if the counsel of a clergyman can 
be invoked ; among certain denominations embryotomy is prohibited or 
deprecated, and such a clergyman may be able to persuade the parents 
against the operation when the physician alone could not prevail. 

Prognosis. Embryotomy is sometimes selected upon the erroneous 
belief that it is always less dangerous to the mother than Cesarean sec- 
tion ; this error has cost more than one maternal life. In highly con- 
tracted pelves embryotomy is more dangerous to the mother than Cesa- 
rean section performed under favorable conditions. It is far more difficult 
and dangerous to extract a large foetus piecemeal through a highly con- 
tracted pelvis, than to remove the same by abdominal incision. Not 
onlv is the danger of sepsis far greater, but severe injury of the bladder 
may occur, and also extensive laceration of the soft parts of the birth- 
canal. 

Like all other operations, it is evident that the success or failure of 
embryotomy must depend largely upon the condition of the mother at 
the time of operation. Unfortunately, most embryotomies must be 
performed in cases where the patient is already exhausted through pro- 
longed and ineffectual labor. Many of these cases have already been 
infected before coming under observation : hence, puerperal septic 
infection readily develops in the bruised and lacerated birth-canal, and 
severe constitutional poisoning rapidly ensues. 

Those methods of performing embryotomy which tend to injure the 
mother's tissues as little as possible are obviously safest and most suc- 
cessful. When the foetal skeleton is severed care must be taken that 
no fragments of bone emerge from the soft parts to wound the maternal 
tissues. In cases where fruitless attempts at delivery have not already 
bruised and lacerated the mother's tissues, embryotomy is most suc- 
cessful. The prognosis of such an operation must, therefore, depend 
not only on the degree of pelvic contraction and the skill of the opera- 
tor, but also upon the condition of the mother's tissues before the oper- 
ation is attempted. 



710 



OBSTETRIC SURGERY. 



The various procedures employed in performing embryotomy may 
be described in connection with various portions of the foetal body. 



CRANIOTOMY 

Consists in opening the foetal cranium and allowing a portion of its 
contents to escape, and then subjecting the; head to pressure in such a 
manner as to lessen materially its circumference. 

Method of Operating. Craniotomy may be done in two way- : one, 
by opening the head through a suture or fontanelle, without removing 
a portion of the bony wall; and the other, by entirely removing a 

Fig. 416. 




Smellie's scissors. 



disk of bone and thus making a permanent opening in the skull. 
In the former, a pointed instrument is thrust into the cranium through 
a suture or fontanelle. (Figs. 418 and 419.) A suitable forceps for 
making traction upon the head is then applied, one blade being inserted 
into the opening in the skull, while the other blade grasps the cranial 



Fig. 417. 




Blot's perforator. 

w r all from without. Traction is then made upon the head, w T hich is 
compressed by the pressure exerted by the pelvic wall. A small por- 
tion of the cranial contents may escape through the opening made, 
while the greater portion of the brain will simply be compressed and 
bruised within the cranium. When the disproportion existing between 
the head and the pelyis is slight, sufficient compression of the skull 
may thus occur to permit of delivery. When, however, the pelvis is 
much smaller than the head, this procedure will scarcely be followed by 
sufficient reduction in the size of the foetal cranium to make a material 
difference in delivery. Where the foetus is small, or where the head is 
easily compressible, or the foetus is macerated, the obstetrician may hook 
his finger into the cranium through the opening made, and by gentle 
but persistent traction may deliver the child. If no suitable forceps 
be at hand, any blunt hook may be passed within the skull, and traction 
made in that wav. 



EMBRYOTOMY. 



Ill 



It is often the case that the head is not so situated that a suture or fon- 
tanelle is available for craniotomy. In contracted pelves, and especially 
in flattened pelves, a parietal bone usually presents at the brim of the 



Fig. 418. 




The use of the simple perforator. 



pelvis. About the centre of this bone is the most available point of 
the cranium for the performance of craniotomy. 

The bone-tissue of the skull may be opened by a pointed instrument, 
the blades of which may be separated after they have been inserted into 



FlG. 419. 




Craniotomy with Martin's trephine. 

the skull, thus cutting in several directions through the cranial wall. 
An excellent example of such an instrument is found in Blot's perfo- 
rator, which is shaped somewhat like the point of a spear, the edges 
of the blade opening and cutting several flaps into the cranial wall. 
(See Fig. 417.) Through this opening a suitable traction-forceps may 
be inserted for the delivery of the head. 



712 



iwsTi-rrnic si'iuucry. 



A more efficient method, however, consists in the use of the obstetric 
trephine: this is essentially the trephine of the Burgeon, placed upon 



Fig. 420. 



Fig. 121. 






Martin's trephine. 



a longer stem to enable the obstetrician to reach upward to the brim of 
the pelvis. As the scalp is often swollen and oedematous in these cases, 



Fig. 422. 




Braun's cranioclast. 



it is sometimes necessary to incise the scalp, and through such an inci- 
sion to apply the trephine directly to the periosteum covering the bone. 



EMBRYOTOMY. 



713 



Usually, however, the centre-pin of the trephine may be thrust directly 
through the scalp and the periosteum, and the blade be brought directly 
down upon the bony tissue. (Figs. 420 and 421.) 

While the trephine, however, may remove a button of bone from the 
cranial wall, it does not remove the cranial contents nor lessen the 
size of the head. When the head has been opened, it is best to thor- 
oughly break up the brain and its membranes with a blunt instrument, 
and then with a strong piston-syringe to wash out the cranium with a 
dilute antiseptic solution : when this has been accomplished, one blade 
of the cranioclast is to be passed through the opening, while the other 
is applied to the external surface of the cranium. The cranioclast is 



Fig. 423. 



\ 




The head after delivery by the cranioclast. 

then firmly locked, and traction is made downward and backward in the 
axis of the pelvic brim until the pelvic floor is reached, when traction 
is continued upward and forward. The best cranioclasts have a perineal 
curve similar to that of the forceps, which aids materially in making 
traction in the proper direction. (Fig. 422.) 

Neither trephine nor cranioclast, however, lessens the size of the 
head ; this must be accomplished by pressure by the pelvic walls during 
the descent of the head. If the cranium be unusually hard, it may be 
impossible so to lessen its size without exposing the mother's soft tissues 
to violence and injury. (Fig. 423.) In these cases the head must 
not only be emptied, but also fully or partially crushed before traction 
is made. 



71 1 



OBSTETRIC SURGERY. 



Crushing Operations, Instruments designed to crush the head arc 
called eephalotribes. They consist essentially of a pairofstoul forceps, 
with a strong compression-screw at the outer ex- 
'•'"• • , -' tremity of the handles. (Fig. 124.) The instru- 

ment is applied in the most convenient manner 
possible lo the Bides of the head, the tips of the 

blades reaching beyond the foetal cranium. By 
applying a compression-screw the skull is then 
crushed ; and if it is essential to thoroughly break 
it up, the cephalotribe may be slightly shifted and 

again applied in the same manner. Especial at- 
tention must he given, in using this instrument, to 
crushing the occipital bone, as it forms the base 
of the skull and is the most resisting point of the 
cranium. 

To accomplish this successfully and thoroughly, 
various instruments have been invented, some of 
which have portions especially designed to crush 
the occiput. Such are called basiotrilx is, and best 
known among them are the instrument of Tarnier, 
and also that of Auvard. 1 (Fig. 425.) These in- 
struments have a long centre-stem or core, termi- 
nating in a screw thread somewhat like that of an 
au^er. The centre-point is bored through the 
wall and directly into the base of the 
When the head has been thus entered, the 
blades of a cephalotribe are applied upon each side 
of the skull, and the cranium thoroughly broken 
up. Extraction is then performed in the usual 
manner. (Fig. 426.) 
Lusk's cephalotribe. Decapitation. In impacted transverse presenta- 

tions of the foetus it may be necessary to decap- 
itate the child : elaborate instruments for this purpose have been 
devised. As is the case with all surgical instruments, the simplest in- 
struments and apparatus for decapitation are most efficient and safest. 
Some have advised passing a simple cord or band around the neck of 
the foetus, and severing the neck by sawing through the tissues with 
the cord : the difficulty of this procedure lies in the fact that it often 
requires skill and patience to pass a cord or band around the foetal neck. 
The simplest instrument which has been found most efficient is the de- 
capitation-hook of Braun; this consists of a long stem, having at one 
extremity a blunt hook, and at the other a transverse handle. The hook 
is fastened over the neck of the child, and by a steady, twisting motion 
the vertebral column is severed. (Figs. 427 and 428.) Modifications 
of this hook which carry a chain-saw or a cutting-band about the neck 
of the foetus have been devised, but they are complicated and elab- 
orate, and objectionable for these reasons. Zweifel {Central hi ait fur 
Gynakologie, No. 20, 1895) finds an objection to Braun's hook because 
the fixed point on which leverage is exerted is placed upon the child's 
neck by this hook ; Zweifel urges that this point should be at the hand 

1 Archives de Tocologie, June, 1889. 




cranial 
skull. 



EMBRYOTOMY. 



715 



of the operator, and for this purpose he has devised double hooks, 
joined, which can be rotated in such a manner as to bring the fixed 
point of force upon the stem and handle of the hooks. (Figs. 429 
and 430.) He appends to his description of these hooks a report of 
several cases ; in one of these, an assistant had attempted decapitation, 
but had omitted the very important precaution of grasping the neck of 
the child with his index- and middle fingers, and carefully determining 
the fact that the hooks were accurately applied to the child's neck. 
The failure to take this precaution had resulted during the decapita- 



Fig. 425. 



Fig. 426. 





Tarnier's basic-tribe. 



Basiotripsy accomplished. 



tion in wounding the neck of the womb so extensively that profuse 
hemorrhage followed, and death from acute ansemia. 

Tarnier's embryotome for decapitation consists essentially of a hook 
carrying a sheathed, linked saw, which is gradually tightened after 
being placed in position : it is possible with this instrument to sever the 
trunk of the foetus at any portion, should it not be possible to reach the 
neck of the child. (Le Progres medical, Nos. 18 and 19, 1888.) 
Where the foetus is large and firmly impacted, considerable difficulty 
may be experienced in performing decapitation with a hook. In such 



716 



OBSTETRIC 8TTRQERY. 



cases Thomson {Deutsche medicinisohe Wochenschrifty No. 30, 1889) has 
had good results by using the sickle-shaped knife <>r Schultz: in eleven 
cases this knife, \\ hich musl be very Bharp to be efficient, worked rapidly 
and very easily. 

When the maternal tissues are relaxed and the child is not large, 
should impaction occur during twin delivery, it may l>e possible to 

decapitate a child horn in hreech presentation by a strong pair of blunt- 



FlO. 427. 



Fig. 428. 




— ■ 




Carl Braun's decapitation hook. 



Decapitation by the hook. 



pointed scissors ; if there is danger that the mother's tissues may be 
wounded, a piece of rubber tubing may be passed about the neck of the 
child, serving as a guard to prevent the scissors from slipping up into 
the uterus. Thus, in a case of locked twins, in which the body of one 
had been born, while the two heads were impacted at the pelvic brim, 
the writer decapitated one of the children readily by this expedient. 

Reduction of the Trunk. For attacking other portions of the foetus 
besides the head, the simplest instruments are most successful. A 
strong-bladed pair of blunt-pointed scissors is an especially valuable 
instrument ; with these, the clavicles may be severed, a foetal limb may 
be amputated, or the foetal neck cut asunder. 

In cases of excessive development of the shoulders great difficulty 
may be experienced in bringing this portion of the child's body through 
the pelvis. If the clavicles be severed, the trunk is instantly greatly 



EMBRYOTOMY. 



Ill 



reduced in transverse measurements, and delivery is usually possible. 
Phanomenoff {Centralblatt fur Gynakologie, No. 22, 1895) has severed 
the clavicles in such cases by the use of large, blunt-pointed scissors. 
He inserts one hand sufficiently far to grasp the clavicle with the 
thumb and fingers, and, with these as guides, cuts through the bone 
with strong scissors. While, theoretically, it might be easier to sever 
the articulations between the clavicle and sternum, still, practically, no 
difficulty is experienced in severing the bone in the manner described. 
Phanomenoff styles this operation cleidotomy. 

In neglected transverse presentations in which the foetus has become 
impacted, evisceration is often demanded before delivery can occur. 



Fig. 429. 



Fig. 48n. 



A 






Decapitation by Zweifel's hooks. 



In these cases Mermann {Centralblatt fur Gynakologie, No. 36, 1895) 
has succeeded by cutting through the ribs with scissors, and emptying 
the chest and abdomen with the hand. 

Craniotomy on the After-coming Head. The after-coming head 
may lodge at the pelvic brim, or within the pelvis, and may demand 
craniotomy. Numerous procedures are recommended in these cases : 
some advise that the head be opened through a fontanelle (Busch) ; 



718 OBSTETRIC SURGERY. 

others advise thai the foremen magnum be opened (Micluelis); while 
Kili;in would make section through the sofil part- beneath the chin, 
and insert a trephine through the base of the skull. Cohnstein would 
open the vertebral canal and push a catheter into the cranium. Donald 

would perforate through the base of the skull by way of the mouth, 

and Ddhrssen would open the vertebral column through the foramen 
magnum. Strassmann {Berliner hlinische Woeken&ckrifb, No. 36, l*'.'!) 

fixed the head by introducing the index and middle fingers into 
the open mouth, and making traction upon the lower jaw. The 
breech of the child was elevated toward the mother's abdomen. A 
scissor-perforator was then passed through the pharynx to the base 
of the skull through the foramen magnum, dividing the bones be- 
tween the 1 occipital condyles and making a large opening. A firm 
catheter was then introduced, and the brain broken up and washed out. 
Traction with the finger in the foetal mouth was sufficient to accomplish 
delivery. This method is urged as requiring no assistant, and being 
especially safe. Demmer (Centralblatt fur Gyndkologie, No. 45, p. 1125) 
perforated through the mouth, using a trephine, thus making a smooth 
and permanent opening. Macan (British Gynecological Jour rial, Xo. 
11, p. 608, 1895) makes an extensive review of the literature of per- 
foration of the after-coming head, and draws attention to the safety of 
perforating through the mouth of the foetus. In a case of hydro- 
cephalus in breech presentation, Lamarche (L > Union medicate cle Can- 
ada, No. 23, 1894) succeeded by drawing the trunk of the foetus well 
downward and to the left, opening the palatine vault with Smellie's 
scissors, and allowing fluid to escape from the cranium. Winternitz 
(Centralblatt fur Gyndkologie, No. 28, 1892) was obliged to make de- 
capitation in a case of breech presentation in a highly contracted pelvis. 
The head was turned by suprapubic manipulation, so that the occiput 
presented. It was then fixed by external pressure, the brain broken 
up and evacuated with the finger, and the head delivered by the cranio- 
clast. The patient made a good recovery. 

Unusual Complications. It occasionally happens that after version 
in contracted pelvis the operator is obliged to do embryotomy, and 
that a portion of the foetus may be retained within the uterus. Thus 
Touvenaint (Centralblatt fur Gyndkologie, No. 22, 1893) was obliged 
to perform embryotomy after version, and extracted the foetus piece- 
meal at intervals during three days : the patient resumed her usual 
occupation ; but a vaginal discharge persisting, she consulted another 
physician, who found a uretero-vesical fistula. The skeleton of the 
foetal head still remained in the uterus. The womb was dilated with 
tents, and the foetal bones extracted by forceps. The patient ulti- 
mately made a good recovery. This case illustrates well the toler- 
ance which the organism manifests to a retained and putrefying 
foetus so long as streptococcus infection is not added to the compli- 
cations already existing. The foetus may become putrefied before 
delivery, and yet the mother be relieved and escape septic infection, a 
temporary saprremia being often the only complication. This is illus- 
trated by a patient delivered during the past winter at the Jefferson 
Maternity, who had lain in labor in a tenement-house for several days, 
the child in transverse presentation and the arm presenting. On 



EMBRYOTOMY. 719 

admission to the Maternity the arm was black and partly decomposed, 
and the shoulder and trunk formed a wedge at the pelvic brim. It was 
necessary to amputate the arm at the shoulder-joint, push up the child, 
and make version to deliver. The mother escaped with a mild attack 
of saprsemia, which yielded promptly to a single intra-uterine injection. 

Craniotomy and Symphysiotomy . Craniotomy is occasionally requisite 
in connection with symphysiotomy. Dimock (British Medical Journal, 
No. 1695, 1893) performed symphysiotomy upon a Hindoo rhachitic 
dwarf; the patient's condition did not justify abdominal section, and 
the pelvic space was so small that embryotomy without symphysiotomy 
was impossible. The foetus was dead before the operation. After the 
symphysis was opened the head was perforated and delivered by the 
cranioclast. The patient made a good recovery. It is evident that 
cases may occur in which the patient's exhausted state renders abdominal 
section unwise, and in which symphysiotomy must precede embryotomy. 
These cases, however, must necessarily be rare, and in many patients 
would prove fully as complicated and dangerous as abdominal section. 
Caruso, of Naples, in the Eleventh National Cougress at Rome (Cen- 
tralblatt filr Gyndkologie, No. 17, 1894), advises symphysiotomy in place 
of Cesarean section where the foetus is dead and the pelvis highly con- 
tracted. Queirel (Annates de Gynecologic et cV Obstetrique, Feb., 1895) 
reports two cases in which symphysiotomy was performed to permit the 
extraction of a dead child. Both mothers recovered. He submits his 
cases to Pinard, asking him his opinion upon the propriety of this pro- 
cedure. Pinard replies that when the child is dead symphysiotomy is 
only permissible when the pelvic contraction is so great that embryot- 
omy, and especially the use of the basiotribe, is exceedingly dangerous. 
He agrees, then, with Queirel in his decision in the cases reported. 
Morisani, in a discussion upon symphysiotomy before the Congress of 
1894, at Rome (Annates de Gynecologie et d' Obstetrique, April, 1894), 
would avoid symphysiotomy when the infant is dead, or in such poor 
condition that its life is a matter of great doubt. In such cases he 
would deliberately elect embryotomy, and views with considerable doubt 
the proposition to combine the two operations when the foetus is in bad 
condition and the pelvis highly contracted. 

Frequency. The frequency with which embryotomy is performed by an 
operator or in a given clinic must depend considerably upon the usage of 
the person or the clinic. A physician accustomed to abdominal section 
and with the apparatus required for such cases would naturally operate 
in this manner upon many patients who might otherwise be delivered by 
embryotomy. Among the extensive statistics upon the subject are those 
of Potocki (Thesis, Paris, 1888), who examined the records of 32,938 
births at the Maternite and Lariboisiere ; there were in these cases 151 
shoulder presentations, in which version was done 119 times. Embry- 
otomy was performed 12 times, and 20 patients delivered themselves 
by spontaneous evolution. Among shoulder presentations, one in four is 
neglected and comes to embryotomy. Nineteen embryotomies are reported 
by this author, with six deaths, one of which was directly caused by the 
instrument employed. Philips (British Medical Journal, June 1, 1889) 
performed 16 craniotomies, with a maternal mortality of nil. Ten of 
these were done upon living children. The smallest true conjugate was 



720 . OBSTETRIC SURGERY. 

2j inches, In several oases the pelvic brim was normal, but the outlet 
was contracted. Polland (Inaugural Dissertation, Berlin, L 895) reports 
'I') embryotomies, with maternal mortality of 4, -■) cases dying of rupt- 
ure of the uterus, and one from deep laceration ol* the vagina. Fourteen 
decapitations were made with the hook, and in ;> ease- this instrument 
Tailed. Strong scissors succeeded where other Instruments were unsuc- 
cessful. In (50 contracted pelves Gueniot (Mercredi fiftdical, No. 18, 
L895) performed embryotomy hut once, and then basiotripsy was em- 
ployed in a ease where the i'oreeps failed to deliver. Kullerath (Cen- 
tralblatt fur Gynakologie } No. 46, 1892), in an extensive survey of* in- 
duced labor, Cesarean section, and embryotomy, would choose the last 
when the mother declined another operation, or when she was in such 
condition that her recovery from Cesarean section would be a matter of 
grave doubt. 

Prognosis. In skilful hands embryotomy is a very safe operation. 
Leopold has done 71 craniotomies, with 2 T 8 Tr per cent, mortality. (Keh- 
rer, Lehrbuch der Operativen Geburtsliulfe, 1891.) Fehling had 4 T 3 g- 
per cent, mortality in 23 craniotomies. Zweifel had 68 craniotomies, 
with 5 deaths, 2 from previous rupture of the uterus, and 3 from 
eclampsia. Zweifel has never lost a case of craniotomy through the 
operation itself. The perforation of the after-coming head is more fatal 
to the mother. It is estimated at the Leipzig clinic that the ratio is 
about 5 to 1. It is difficult to compare the records of European 
clinics upon embryotomy with those of the United States. It is only 
within recent years that pelvimetry has become sufficiently common to 
lessen the fruitless attempts at delivery in contracted pelves, which pro- 
duce so great mortality. Edgar (American Journal of Obstetrics, vol. 
27, 1893), among 3225 confinements at the Lying-in Hospital of New 
York, had but one embryotomy. Extreme degrees of pelvic contrac- 
tion calling for embryotomy are less common in American clinics than 
in those of Europe. 

Relation to Other Procedures. In concluding the discussion on the 
subject of embryotomy, it is proper to review the grounds upon which a 
choice between embryotomy, Csesarean section, and symphysiotomy must 
be made in the present stage of obstetric surgery. As has been said, a 
physician practising where competent assistance can be obtained and 
antiseptic precautions observed is fully justified in absolutely declining to 
destroy the life of an uninjured and normally vigorous foetus. If, how- 
ever, he cannot command proper help and aseptic environment, he must 
consult the mother's interests first, and may then consent to embryot- 
omy upon the uninjured child. In cases where ineffectual attempts have 
been made to deliver with forceps it is extremely probable, if not almost 
certain, that the foetus has been so injured that its recovery is doubtful 
or impossible, and that the mother has been infected. The physician 
summoned to such a case must take these circumstances into account in 
deciding on operation. He may thus elect embryotomy, even if com- 
bined with symphysiotomy, rather than abdominal incision. It must, 
however, be remembered that if the womb is already septic and the 
patient's strength be good, it may be safer for her to deliver by abdom- 
inal section, followed by hysterectomy. In cases of rupture of the 
uterus the operator must first ascertain whether the foetus cannot be 



EMBRYOTOMY. 721 

removed through the vagina by embryotomy, if necessary. If the rent 
in the womb is but a partial or slight one, embryotomy should be per- 
formed, the uterus disinfected, and the rupture tamponed with sterile 
gauze. In cases of extensive rupture, with escape of the foetus into the 
abdomen, abdominal incision is necessary. 

Precautions. It is of the utmost importance in cases of embryotomy 
that thorough antiseptic precautions be observed. After the removal 
of the foetus the uterus must be thoroughly emptied. It should be 
copiously douched with bichloride of mercury solution (1 : 8000), or cre- 
olin(l per cent.). Its cavity should be tamponed with iodoform gauze, 
and a lacerated cervix should be at least partially closed with chromi- 
cized catgut. Tears in the pelvic floor and perineum should also be 
sutured. The vagina should be tamponed with bichloride gauze, and 
the gauze dressing of the uterus and vagina should remain undisturbed 
for forty-eight hours. If injury to the bladder is suspected, permanent 
drainage by a catheter and long tube should be practised. 

The operator must always remember that embryotomy is a most dis- 
tressing procedure for the patient and her family. If possible, no 
member of the family should witness the operation. Under no circum- 
stances should the mother see the child after its delivery. If possible, 
the scalp should be sutured, or other portions of the integument brought 
together, so that the sight of the foetal body should be as little distress- 
ing as possible ; a display of instruments for embryotomy is most un- 
fortunate and ill-advised. Care should be taken that the brain be 
thoroughly broken up before the child is delivered. Distressing in- 
stances are on record where reflex movements of the foetal limbs have 
led to a suspicion that the child survived the operation. 

46 



CHAPTER XXXIV. 

OdESABEAN SECTION. PORRO OPERATION. SYMPHYSIOTOMY. 

CESAREAN SECTION. 

CiBSABEAN section is an obstetric operation for the delivery of the 
child at term by means of an incision through the abdominal and uterine 
walls. But since our better knowledge has rendered it no Longer neces- 
sary to limit the procedure to the dead or dying, and since we can often 
decide months before whether or not it will be advisable to deliver a 
certain patient in this manner, the gynecological beds in our hospitals 
now get their share of these patients, who formerly were assigned to the 
lying-in wards. 

It is commonly assumed that Cesarean section takes its name from 
Caesar, who is said to have come into the world in this way. Pliny, 
however, derives the term from the Latin ccedere, " to cut," and men- 
tions several other celebrities of ancient times, among them Scipio 
Africanus and Manilius, as being among the number of " Ccesones," as 
they were called. 

The practice of Caesarean section belongs to prehistoric times. The 
Romans had a law, ascribed to Numa Pompilius, which forbade the 
burial of a pregnant woman before the foetus had been taken away from 
her, and this was generally done through an abdominal incision. 

The first recorded Cesarean section on the living woman was per- 
formed in the year 1500 in Switzerland, by one Jacob Nufer, a butcher, 
who is said to have saved the life of his wife in this way. It is further 
stated that he operated many times. The procedure subsequently passed 
from the hands of the butchers into those of the barbers. 

In Germany, Trautman was the first to deliver a child through an 
incision in the uterine wall. He operated in 1610, in a case of hernia 
of the gravid uterus. In 1881 Rousset published a treatise in French 
on this subject, and cited nine cases, to which six were added by Casper 
Bauhin in his Latin translation of Rousset' s work. Many authors have 
since tried to prove that these were not cases of genuine Csesarean sec- 
tion, but were simple laparotomies for ectopic pregnancies. It is diffi- 
cult to believe that operation for extra-uterine pregnancy could have 
been so common in those days. 

The procedure, as might indeed have been expected, met with a great 
deal of opposition for many years from various obstetricians. After the 
beginning of the present century, however, many attempts were made 
to perfect the operation, and there was formerly much discussion as to 
the place at which the abdominal incision should be made. Since 
Deleurye's time, however, it has been generally agreed that the incision 
should be made in the median line. 

A great deal of discussion has been directed to the treatment of the 
wound in the uterus. In former times the uterine wound was left un- 
sutured. Sanger and Kayser have done great service in showing that 

(722) 



CESAREAN SECTION. 723 

the suturing of the divided wall of the uterus is without danger, if the 
material employed is absolutely clean. 

Porro recommended that the older operation should be supplemented 
by the removal of the uterus. 

It having been once shown that so many children were saved in this 
way after the death of the mother, the question arose whether it would 
not often be right in cases of protracted labor, and where the life of the 
child, although not that of the mother, was threatened, to perform 
Cesarean section. The proposal, however, met with bitter opposition. 
It was urged that to open the abdomen of the mother, even when her 
condition is hopeless, in order to save the child, is a criminal procedure, 
and Yirchow cites an instance in which a physician was prosecuted for 
performing Caesarean section on a dying woman, with the hope of saving 
the child. 

Indications. The indications for Cesarean section may be divided 
into (1) absolute and (2) relative. 

Caesarean section on the living woman should be undertaken in cases 
in which there is no prospect that the foetus, even after embryotomy, can 
be extracted by the natural passages with less danger to the mother. In 
pelves measuring 6.5 cm., about 2J inches, in the conjugate diameter with 
a living child, or 5 cm., 2 inches, with a dead child, Caesarean section is 
necessary to save the mother's life. Here the indication is absolute, be- 
cause no other less dangerous alternative presents itself. 

In pelves with a conjugate diameter of over 6.5 cm., 2-J- inches, 
symphysiotomy, the induction of premature labor, or embryotomy, be- 
ing simpler and safer procedures for the mother, must be considered. 
Here the indication for Caesarean section is only relative. 

With a conjugate diameter of more than 6 cm., 2^ inches, it is al- 
ways possible by means of craniotomy to bring away the child through 
the natural passages. If the child is dead, perforation is preferable. 
If, however, the child is alive, the physician has to choose between per- 
foration and Caesarean section. Zweifel expresses the opinion of to-day 
in the following words : " Caesarean section must be preferred to crani- 
otomy in these cases, because it renders it possible to save the life of both 
mother and child." 

The statistics of the operation are improving, and ZweifePs recom- 
mendation is generally accepted. ^Nevertheless, no absolute rule can 
be laid down which will meet all cases. All the circumstances must be 
taken into consideration, and each case must be decided upon its own 
merits. A physician, when unable to obtain assistance, is in quite a 
different position from that of an operator in a hospital, who has every 
convenience ready at a moment's notice, and who can command a full 
corps of assistants. A thoroughly aseptic craniotomy and subsequent 
delivery through the natural passages can be accomplished with the 
assistance of only one physician to give the anaesthetic, if the holder be 
employed to keep the legs in position. Such operations have indeed 
not rarely been performed by the obstetrician alone. When, however, 
good assistants can be obtained and all the surroundings are favorable, 
with a healthy child in the uterus and the mother in good condition, the 
danger to the latter will be but slight, and the life of the former will be 
almost certainly assured by Caesarean section. 



72 \ OBSTETRIC SUBOEE v. 

since the majority of Cesarean sections are performed upon patients 
who at -nine lime or other have suffered from rachitis, if the woman 
gives a history of having been very late in Learning to walk, or shows 
definite symptoms of a previous rachitic condition, an examination 
should always be insisted upon early in the pregnancy, to decide whether 
any narrowing of the pelvis exists. If the measurements of the pelvis 

arc decided upon in good time, we shall be able to -elect our method of 
procedure, and thus be better prepared to meet any emergency. 

The time at which the operation should be performed is at the cud 
of pregnancy. By the history and symptoms, and by accurate measure- 
ments combined with palpation, it is possible to decide approximately 
when the foetus is mature. It is not accessary to wail until the labor- 
pains come on in order to secure contraction of the uterus alter delivery; 
neither is it necessary to wait for marked dilatation of the cervix to in- 
sure drainage from the uterine cavity afterward. 

Preparation. A careful chemical and microscopical examination of 
the urine should have been made previously on more than one occasion. 
The patient should have been kept, if possible, under observation for 
some time, and should have received a daily bath and tepid vaginal 
douches of a litre of a 2 per cent, carbolic acid solution or a half-satu- 
rated solution of boric acid. The bowels should have been carefully 
regulated. 

On the evening preceding the operation the abdomen should be pre- 
pared aseptically as for an ordinary cceliotomy. The abdomen and pubes 
are shaved, and a compress of bichloride (1 : 1000) is applied and kept 
on until the patient is brought to the operating-table. 

The Operation. After being anaesthetized, the patient should be 
placed on the table with the buttocks resting upon the perineal pad. 
The vagina should be thoroughly cleansed, every fold being exposed, by 
scrubbing with soft soap on a ball of absorbent cotton held in stout 
forceps. It should afterward be irrigated with a 10 per cent, solution 
of creolin. 

About a drachm of iodoform and boric acid powder (1 : 7) is then 
thrown up into the vault of the vagina, the cavity being afterward filled 
with a pack of iodoform gauze. The toilet of the abdomen is then 
completed in the usual manner. The operator should by external and 
internal examination obtain a clear idea of the position of the child in 
the uterus. Just before the final cleansing of the abdomen the strength 
and frequency of the foetal pulse should be noted. 

The upper abdomen, the chest, the thighs, and the flanks are covered 
with sterilized towels ; a large piece of gauze of four thicknesses covers 
the whole body from the chest to the knees, a slit being cut in it from 
the navel to the symphysis. If the head is wedged in the pelvis, the 
towels and gauze which cover the upper part of the thighs should be so 
arranged that an assistant can exercise upward pressure with the hand 
through the vagina during the extraction of the child. 

The operation is often done in from twenty to twenty -five minutes ; 
sometimes it takes three-quarters of an hour. Gibson, of Philadelphia, 
in 1831, did it in ten minutes, but in this case no uterine sutures were 
employed. In addition to the usual dressings and accessories the in- 
struments needed for the operation are : 



CESAREAN SECTION. 725 

1. Scalpels; 

2. One dozen artery- forceps ; 

3. One pair of scissors ; 

4. A large thin-walled rubber tube as a uterine ligature ; 

5. Needles threaded, with carriers ; 

6. Needle-holder. 

The length of the abdominal incision varies according as it is decided 
to bring the uterus out of the wound before opening it, or to incise it in 
situ. With the first method the uterus can be kept under better control, 
time is saved, and it is easier to prevent the entrance of fluids into the 
abdominal cavity. But against this must be put the great length of the 
incision, which presents the following disadvantages : (1) an extensive 
scar, with consequent weakening of the abdominal walls, often followed 
by hernia ; (2) the greater extent of adhesions occurring later between 
the uterus and the abdominal wall, which are likely to be in proportion 
to the size of the cicatrix. Upon this point Zweifel lays great stress. 
With the second method an incision of 15 cm., 6 inches, will usually be 
sufficient, and this shorter incision is generally to be preferred. The 
description v/hich follows will deal, therefore, more especially with a 
Cesarean section in which the uterus is incised and evacuated before it 
is brought out of the wound. 

The incision extends from a point about 4 cm., 1^ inches, below the 
umbilicus to within about a similar distance from the symphysis. The 
abdomen is opened by first cutting through the skin and fascia and 
between the muscles. An assistant, with a pair of forceps, now catches 
and raises up a small portion of the peritoneum, and the operator, with 
a second pair, takes hold of another portion at a point a short distance 
from the first pair. A nick is then made between the two forceps, and 
the operator, having introduced the finger into the opening and using it 
as a guide, cuts through the remainder of the peritoneum. The uterus 
is now brought into view, and an elastic ligature is passed over the 
fundus and placed around the lower segment. The two ends are held 
by an assistant, who exercises traction, compressing the uterus and fix- 
ing it against the symphysis. The latter procedure serves two pur- 
poses ; it keeps the uterus steady and at the same time prevents exces- 
sive hemorrhage. 

The location of the placenta may sometimes be recognized as a slight 
prominence. This portion of the organ will also appear more vascular 
and feel doughy on pressure. It was formerly taught that the incision 
through the uterine wall should always be made to one side of this area, 
but with our present methods this precaution is unnecessary. 

The uterus is incised from the fundus to a point just short of the re- 
traction-ring. The incision is carried boldly through the whole thick- 
ness of the uterine Avail, notwithstanding the bleeding, which may be 
quite free. 

If the placenta lies in the way, the edge is detached and pushed to 
one side. When the placenta does not underlie the incision, the mem- 
branes will be seen pouting through the incision and presenting a black- 
ish appearance. 

The assistant now presses the abdominal wall toward the sides of the 
uterus, and the operator, passing his hand through the membranes into 



726 OBSTETRIC SURGERY. 

the uterine cavity near the fundus, grasps the nearest extremity and, 
drawing it out, rapidly extracts the child. 

It i- preferable to seize the Leg, if it can readily be found; l>ut the 
child may be delivered by the arm or buttock, if either <>f these pre- 
sents instead. Usually the uterus now contracts, and bleeding is in the 
main controlled. 

Fritsch recommends a transverse uterine incision at the fundus. 
Jewett has operated by this method, with success. Midler opens the 
Uterus at the fundus, but longitudinally instead of transversely. The 
chief advantage of the fundal incision is greater security in closing the 
wound. It insures the avoidance of the lower non-contractile portion 
of the uterus, in which it is difficult to close the wound securely. 

While an assistant holds the child in a large piece of sterilized gauze, 
the operator applies two clamps to the umbilical cord and cuts between 
them. The child is then handed over to an assistant and the stump of 
the cord is ligated at leisure. 

When this has been done, the hand is inserted into the uterus and 
grasps the foetal surface of the placenta. The fingers are then closed 
upon it, squeezing it like a sponge. In this way it is freed from its 
uterine attachment and gradually withdrawn, the membranes being 
peeled off from the uterine wall until both placenta and secundines can 
be delivered. 

The uterine wall has thus far been protected by the amniotic mem- 
branes from risk of infection. If left untouched, it remains aseptic. 
As a rule, by this time the hemorrhage will be slight ; but should it be 
excessive the flow may be temporarily controlled by an assistant, who 
should grasp the uterus below the body or tighten the ligature around 
the lower segment. 

The objection to tying the rubber ligature in every case lies in the 
fact that tight and prolonged constriction may paralyze the nerves and 
favor uterine relaxation and subsequent hemorrhage. The uterus should 
be stimulated to contract by friction and by the application of hot towels, 
and, if need be, by faradism. The same object is promoted by the sub- 
cutaneous injection of a half drachm of fluid extract of ergot immedi- 
ately before the abdominal incision. Oozing may be checked by the ap- 
plication of cheese-cloth sponges wrung out of hot water. 

The contracted uterus is now lifted out of the abdominal cavity and 
laid upon a large piece of sterilized gauze, which also serves to prevent 
protrusion of intestines. It is a routine practice to sprinkle about half a 
gramme, 8 grains, of iodoform powder into the uterine cavity to check 
the secretions and keep the discharge sweet should the surface not be 
absolutely aseptic. 

Where labor-pains have been present the appearance and position of 
the contraction-ring should be noted. 

The uterine incision is now closed with a row of deep silk sutures, 
half-deep sutures being inserted between for accurate approximation. 
Finally, a row of superficial sutures is so placed as to cover in the deep 
layers. (Fig. 431.) The first sutures should be laid at intervals of about 
1.5 cm. apart, being introduced on the peritoneal surface of the uterus 
about half a centimeter from the edge and brought out on the wound 
surface just where the decidua and muscularis come together. The line 



CESAREAN SECTION. 



727 



of separation is easily recognized. They are then entered on the oppo- 
site surface of the wound at corresponding points and brought out on 
the peritoneal surface of the uterus on a line with their points of en- 
trance. If hemorrhage is still going on, these sutures should be tied 
as soon as possible after their introduction, until the bleeding points are 
reached and the flow is controlled. 

Each suture is tied firmly enough to bring the surfaces snugly to- 
gether and stop hemorrhage from the wound as well as from the suture- 
punctures. Slight blanching of the surrounding tissues at the point of 
entrance and exit will show when the sutures are tight enough. If they 
are too tense, the circulation will be completely cut off from the wound 

Fig. 431. 




Diagrams to show the placing of sutures in the uterine wound after Csesarean section. (Sangek.) 
p. Peritoneum. F. Uterine fibre, m. Mucous or decidual layer, u. Deep uterine sutures, s. Super- 
ficial serous suture. 

and the risk of septic infection will be rendered greater by the decreased 
resistance thus produced. The half-deep or superficial sutures are next 
inserted. 

The deep sutures are completely covered in and concealed by the 
introduction of a layer of superficial sutures along the whole length of 
the wound. Fine silk may be employed for the latter. Each of these 
is made to enter and emerge on the peritoneal surface just outside the 
line of the deep sutures, and should include just enough tissue to secure 
a firm hold. The suture is then carried across the incision and through 
a fold of peritoneum on the opposite side. The peritoneum is thus drawn 
over the deep sutures, forming a welt which covers the wound in the 
uterus. This method of suturing the serosa is analogous to the intes- 
tinal sutures devised by Czerny and Lembert. 

The placing of a row of superficial sutures provides against the 



728 OBSTETRIC SURGERY. 

invasion of the peritoneal tract better than any other method, and is 
especially useful where the Labor has beeu prolonged and forceps or 

other manipulation- have been employed, whereby the patient has be- 
come much exhausted. 

Where it is reasonably certain that no infection has been possible 
before the abdominal operation the superficial or subserous suture maybe 

omitted. After all the sutures have been introduced, if everything has 
gone right, the wound surface should remain dry. 

Instead of the foregoing method Palmer Dudley uses running catgut 
sutures in two or three tiers. 

The uterus being now drawn forward, the gauze covering the intes- 
tines is removed and the peritoneal surfaces are cleansed of blood and 
liquor amnii by gently pressing them with a dry cheese-cloth sponge. 

Particular attention should be paid the renal fossa?, a fresh, clean 
sponge on a holder being carefully carried up into each. The surface 
of the intestines and of the pelvic cavity behind and in front of the 
uterus and broad ligaments should also be sponged clean. The uterus 
is now replaced within the abdomen, with its anterior surface facing the 
abdominal wall. 

For future reference it is well to make a direct internal measurement 
of the conjugata vera, using for the purpose a sterilized sound. 

The omentum should be brought down and carried behind the uterus, 
instead of in front of it, in order to avoid the formation of omental 
adhesions, which otherwise not infrequently give rise to subsequent 
pains in the hypogastrium and epigastrium after the uterus has con- 
tracted down. 

Tn case of infection there is a liability that a pocket of pus may col- 
lect in front of the uterus and be discharged subsequently through the 
lower angle of the abdominal wound. 

After the uterus has been replaced the abdominal wound is closed by 
means of a continuous silk suture for the peritoneum, interrupted silver- 
wire sutures being employed to bring together the muscles and fascia, 
and buried running sutures for the skin. 

The occlusive abdominal dressing is applied and held in place by a 
suitable bandage. 

The vulvar orifice having been relieved of its pad, the urine is drawn 
and a drachm of iodoform and boric acid powder (1 : 7) is thrown 
into the vagina, after which the vulva is covered with a loose pad of 
absorbent cotton ; this is changed every three or four hours at first, and 
as often as the urine is drawn more powder is thrown into the vagina. 

After-treatment. The after-care of the patient is very important. 
It may be necessary to give one or two hypodermic injections of mor- 
phine (^— ^ gr.) to insure the patient a good rest on the first night. 
After the first twenty-four hours there will be but little pain, and the 
hypodermic injections under ordinary circumstances must not be con- 
tinued. The child should be put to the breast after twenty-four hours, 
and subsequently at regular intervals of two hours during the day, and 
once or not at all at night. 

The bowels of the patient should be opened on the third day, which 
will be early enough if they have been thoroughly evacuated before the 
operation. 



THE PORRO OPERATION. 729 

As soon as she is able, she may be allowed to pass her water, and 
after each act of urination the parts should be cleansed by irrigating 
with boric acid solution. 

The continuous suture may be removed about the tenth or twelfth 
day. After two weeks the patient may be lifted out of bed and allowed 
to remain for a short time each day in a reclining-chair. During the 
third week she may sit up for a part of the day, and during the fourth 
week may begin to walk. An abdominal bandage should be Avorn for 
several months, or even a year. 

It is important to determine the position and size of the uterus two 
or three months after the operation, and to ascertain whether any fixa- 
tion to the abdominal wall exists. 

In addition to the foregoing, the following points in the technique of 
the operation are worthy of mention : 

1. In private practice the operation is most frequently performed at 
the patient's home, and since to-day we ought tc preserve almost equally 
well our aseptic technique in a private houie as in a hospital, care 
should be taken that all necessary preparations are made beforehand, 
and not left till the operation has begun, [in this way the different 
steps may follow one another with the utmost rapidity consistent with 
accuracy and attention to detail. 

2. If the uterus has probably been inty/ted before operation, the 
conservative Csesarean section is not sufficient, and the whole organ 
must be removed. 

3. Drainage must be provided for by way of the cervix. 

4. The routine use of a vaginal douche after the operation is not 
indicated. 

THE PORRO OPERATION. 

Porro preferred to supplement the ordinary Cesarean section by am- 
putating the uterus in its lower segment, the tubes and ovaries being 
also removed. The advantages claimed for this operation, which is 
more mutilating than the one just described, are as follows : 

1. There is no risk of hemorrhage from the uterine incision either 
during or after the operation ; 

2. There is no uterine wound to suture — this saves time ; 

3. The wound is entirely outside the peritoneal cavity, and hence the 
danger of sepsis is diminished ; 

4. The woman will never again be put in the same dangerous 
situation. 

Indications. The Porro-Csesarean section is, therefore, indicated : (1) 
When the labor has been prolonged, the membranes have been ruptured 
for some time, and manipulations have been undertaken involving the 
uterus which make the occurrence of sepsis very probable. (2) When 
the uterus or appendages are diseased to such an extent that a subse- 
quent operation will certainly be necessary for their removal. (3) 
When tumors are present in the pelvis or vagina, or the latter has 
undergone an abnormal narrowing from cicatrices, rendering the delivery 
of a subsequent child impossible, it is certainly justifiable, with the con- 
sent of the patient and her relatives, to prevent by Porro's operation the 
recurrence of pregnancy, which has already proved so dangerous. 



730 OBSTETRIC SURGERY. 

The technique of the operation is, in the firsl steps, the same as in 
the one just described. After the rubber Ligature has been placed 
around the lower segmenl of the uterus it is tied tightly to control 
the circulation. A pad of gauze is drawn behind the fundus, down to 
the ligature, to catch the fluids coming from the uterus and thus 
prevent them from entering the abdominal cavity. After it has been 
evacuated the uterus iscut rapidly away at a point 2£ or 3 cm. above 
the ligature, and the tubes and ovaries are also removed. The opera- 
tion is completed by ligating the ovarian vessels and each of the uterine 

Is in the stump. The part of the uterine cavity above the rubber 
ligature is disinfected with pure carbolic acid, applied by means of absorb- 
ent cotton on an applicator. 

The contents of the cervical canal should, if possible, be prevented 
from coming in contact with the wound. If proper disinfection has 
been carried out, this matter is less important. 

The abdominal wound is now closed down to the stump, the peri- 
toneum around the lower angle of the wound being attached by a run- 
ning suture on all sides to the pedicle, thus completely shutting off the 
peritoneal cavity. 

The stump is kept from retracting into the abdominal cavity and 
slipping out of the knot by forcing two sterilized knitting-needles 
through both the rubber ligature and the stump together. These 
needles rest upon pads which protect the surface of the abdomen. Iodo- 
form gauze is packed in and around the stump on all sides, and the iodo- 
form and boric acid powder used freely. 

Thick pads of sterilized gauze are laid over the incision ; over these 
come cotton, and lastly the bandage. In two or three days the dress- 
ings, if saturated, should be changed ; otherwise, if there are no indi- 
cations of sepsis, they may be left on for five or six days. 

The vaginal pack should be renewed every two days. If suppura- 
tion is present, the dressings should be changed daily. After from 
twelve to fifteen days the distal part of the stump with the rubber 
ligature separates as a slough and comes away, leaving a retracted granu- 
lar pit. 

The chief advantage gained by the extra-peritoneal method of treat- 
ing the stump consists in a saving of time. If the patient is in good 
condition, many operators employ the subperitoneal method, which is now 
so often used after supravaginal amputations of the non-gravid uterus. 
For a detailed account of the procedure, text-books on gynecology may 
be consulted. 

Vesical disturbances do not generally arise in these cases, there being 
abundant room in which the bladder can expand. 

SYMPHYSIOTOMY. 

Symphysiotomy (from abfupomz, a joint, and rojuij, a cutting) is an 
operation for the artificial division of the pubic symphysis in woman 
in labor, in order to increase the diameters of a narrowed pelvis, 
and thus to permit the birth of a living child through the genital 
canal. 

History. The operation was performed on a dead woman, in place of 



SYMPHYSIOTOMY. 731 

a post-mortem Cesarean section, for the purpose of saving a living 
child, by Jean Claude de la Courvee, at Warsaw. The date is var- 
iously given as 1644 and 1585. A similar operation was performed by 
Joseph Plenck in 1776. That a separation of the pelvic bones exists 
during the later months of pregnancy was recognized even in the early 
days of medicine, and allusions to it can be found in the works of 
Hippocrates and Avicenna. Galen held that the pubic symphysis was 
a true joint, while Yesalius taught that the pelvic bones were united 
by cartilage. In 1519 Jacques Amboise conducted a careful autopsy 
on the body of a woman who had been executed a few days after labor, 
for child-murder, and demonstrated that a separation of the pelvic bones 
existed, with no sign to show that it was other than a normal physio- 
logical condition. Severin Pineaud, who assisted at the examination, 
deemed the findings of such importance that he incorporated them in a 
brochure, w T hich, however, w T as not published till 1775. The symphysis 
was found to be markedly affected, the synchondrosis being much soft- 
ened, owing to an apparently physiological succulence of the tissues, 
which was ascribed to pregnancy. 

It was, no doubt, the knowledge that a certain degree of separation or 
relaxation of the pelvic joints exists normally during pregnancy, which 
suggested the possible advantage of the operation upon the living woman. 
Such a procedure is certainly an attempt at a close following of Nature's 
own method of preparing the pelvis for the passage of the child, and 
goes only a step farther in that it makes disruption of a joint where 
nature has provided only a relaxation. 

Although the credit of proposing the operation on the living woman, 
with the intention of delivering a viable child, belongs to Rene Sigault, 
who, while yet a student in Paris, advocated the procedure in 1768 
before the French Academy, an Italian surgeon, Domenico Ferrara, 
who had been in Paris, and who was acquainted with Sigault' s views, 
was first to carry out the suggestion. Ferrara operated in Naples, in 
1774. The woman died. Sigault himself performed his first symphysi- 
otomy in 1777, at Paris. The patient was a soldier's wife, who had 
previously given birth to four children, all born dead. The conjugate 
w T as said to have been about 6.5 cm, 2J inches. The operation was 
successful, and the woman had so far recovered in two months that she 
was able to leave her house and was presented for examination by Sigault 
at a meeting of the Faculty of Medicine. The Academy of Surgeons, 
with Baudelocque at its head, bitterly opposed the new operation. 
Their position was strengthened by the facts that Sigault's patient was 
left with a vesico-vaginal fistula, and that she also suffered from pro- 
lapse of the vaginal walls and of the uterus, and had an unsteady, wad- 
dling gait. In spite of this relatively ill success and the condemnation 
of the procedure in high places, Sigault w T as hailed by many as a public 
benefactor, and several similar operations were performed. Although 
the results by themselves would go to show that the hostility of the 
French surgeons was not without some show of reason, it must be re- 
membered that : (1) the limits of the operation had not been worked out ; 

(2) methods of pelvimetry were crude and imperfect, and it could not 
be otherwise than that the operation would be applied in unsuitable cases ; 

(3) cases, many of them ill chosen, were operated upon under different 



7:;^ OBSTETRIC SURGERY. 

circumstances by various surgeons, some of whom did uol possess the 
requisite skill, in the lighl of modem discoveries it is to these factors 
thai in a erreat measure must be ascribed the high rate of mortality in 
the mothers, w hich was even exceeded by the fatalities in the case of the 
children. Sigaull himself operated (J times, and lost 1 mother and 5 
children. De Cambon operated 4 time.-, and lost 1 mother and 2 chil- 
dren. Leroy operated 1 times, and losl 1 mother and 1 child. 

Harris' statistics show that in 105 symphysiotomies performed be- 
tween 1777 and 1866 the maternal mortality was 31 per cent., while 1 5 
percent, of the children died. Neugebauer records 136 eases between 
1776 and 1866,56 of which were performed in Italy. Of these 56 
eases, '2'2 mothers recovered, and 18 died; in 16 the results are not 
recorded. Of the children, 16 were born alive, 22 died; in 16 the re- 
sults are uncertain. Between 1815 and 1841 Galbiati operated 18 
times. From about 1820 to 1890 the operation was almost entirely 
confined to Naples. Harris states there were no reported cases between 
1858 and 1865, when Bellozi, of Bologna, operated, but lost the mother. 
Morisani, of Naples, in 1866, working in the same hospital in which 
Ferrara had performed his first symphysiotomy, carried out the pro- 
cedure successfully; mother and child both survived. From this time 
the operation began to be more generally employed, though up to 1890 
the majority of all symphysiotomies had been done at Naples by Moris- 
ani and his pupils. Harris, writing in 1883, says that in the seventeen 
years preceding more symphysiotomies were performed in Italy than in 
the rest of the countries of the world put together. In 1881 Morisani 
published 50 cases, with 80 per cent, of successes, 41 mothers and 41 
children surviving. In 1885 the same authority published 18 addi- 
tional cases : 10 mothers and 13 children living. 

In 1891 Spinelli, a pupil of Morisani, went to Paris to lay the results 
obtained at Naples before the French profession. Between 1888 and 
1891 he collected 24 cases, out of which 24 mothers and 23 children 
were saved. His results and those of Morisani made a favorable im- 
pression upon Pinard, who became an earnest advocate of the operation, 
and performed 19 symphysiotomies in something over a year, saving 19 
women and 16 children. 

The first reported case in America has generally been ascribed to 
Jewett, who operated on September 30, 1892, although Dr. Joel Wil- 
liams, of William Penn, Texas, claims to have performed a successful 
symphysiotomy twelve years previously. Barton Hirst, of Philadel- 
phia, did the operation a few days after Jewett. 

Symphysiotomy was introduced, in the main, as an alternative for 
Csesarean section. The maternal mortality in the latter, as originally 
practised for over eighty years, had been approximately 100 per cent., 
and it can hardly be wondered that any procedure which promised bet- 
ter results should be hailed as a godsend. The history of all new oper- 
ations w T as repeated. Cases were subjected to symphysiotomy where the 
conjugata vera was so small, or where the pelvis was so deformed, that, 
as Baudelocque demonstrated, in spite of symphysiotomy, it was impos- 
sible to make the head engage. Such cases were manifestly ou-t of the 
province of symphysiotomy. Again, the technique of the operation was 
faulty. The bladder and urethra were often horribly injured. The 



SYMPHYSIOTOMY. 733 

peritoneal cavity was in many instances laid open, and sepsis was a fre- 
quent result in these early operations. In some of the fatal cases, even 
where the conjugata vera did not measure under 2^- inches, 6.5 cm., the 
sacro-iliac joints were found ruptured and filled with pus. 

Baudelocque, who, as has been said, was bitterly opposed to the oper- 
ation, gave it as his opinion that : (1) it should not be done in cases 
where the conjugata vera measured less than 7 cm., 2.75 inches ; (2) 
during the operation and extraction of the child the divergence of the 
pubic bones beyond 2.5 cm., 1 inch, should not be permitted, for fear 
of injury to the sacro-iliac joints ; (3) where the conjugata vera was over 
7 cm., 2.75 inches, the spontaneous delivery of the child should be 
awaited, or other methods less dangerous than symphysiotomy — for 
example, the forceps or version — should be employed. 

It is quite interesting, in reviewing the history of the subject at the 
present day, to look back a few years. In the edition of his book on 
midwifery, published in 1889, Zweifel says : a This operation is obsolete, 
and is only mentioned on account of its historical interest. The whole 
conception is faulty, and I shall here give my reasons why no return 
should be made to this method either in its original or any modified 
form." Zweifel did not stand alone in this condemnation of symphysi- 
otomy, and his ideas, as stated at that time, represented those of the 
leading obstetricians. 

Present Status of the Operation. Since the advent of antiseptic sur- 
gery the statistics of the operation have greatly improved. In 210 
cases operated on since 1886, 1 12.85 per cent, of mothers and 20.2 per 
cent, of children died. These operations were performed by all sorts 
of surgeons, possessing varying degrees of skill, dexterity, and surgical 
judgment. If the results of the best operators be taken by themselves, 
the mortality will be found to be much less. Morisani, for example, 
in 55 cases lost 3.5 per cent, of mothers and 5.5 per cent, of children. 
Zweifel, of Leipsic, Avhose former condemnation of the operation has 
already been referred to, in 23 cases lost 2 children and no mothers. 

Indications for the Operation. Veit and Olshausen 2 contend that fix- 
ing the indications for symphysiotomy is an exceedingly difficult task, 
and that it requires wide experience to decide rightly when this pro- 
cedure is to be chosen in preference to other obstetric procedures. 
Morisani limits symphysiotomy to cases in which the conjugate lies 
between 6.7 and 8.1 cm., 2.6-3.2 inches. The operation properly 
holds a position midway between Cesarean section on the one hand, and 
artificial, premature labor or version at term, on the other. It is 
peculiarly fitted to replace the various forms of embryotomy in cases 
where the conjugate is narrow enough to forbid the selection of version 
at term or the induction of premature labor, and yet is not so small as 
to render Cesarean section imperative. 

Leopold 3 remarks: " How great is the contrast between perforation 
and symphysiotomy ! In both cases the same low maternal mortality 
(1.6 per cent, and 1.7 per cent, respectively); but, on the one hand, all 
the children dead, and, on the other, almost 90 per cent, born alive ! 

1 Xeugebauer, 1893, Ueber der Eehabilitation der Schamfugentrennung, etc. 

2 Schroder's Lehrbuch der Geburtshulfe, 1893. 

3 Arbeiten aus der Koniglichen Frauenklinik in Dresden, 1893. 



7:;! OBSTETRIC SURGERY. 

With Cesarean section perhaps as many children are saved, but the 
percentage of maternal deaths is multiplied two and one-half times. 
Symphysiotomy enables as to limit more narrowly the performance of 
perforation, and thus decreases infant mortality. It diminishes the 
number of Ceesarean sections <>n the relative indication, and thus 
decreases the maternal mortality. Nevertheless, until the limits, the 
indication.-, and the conditions of symphysiotomy are more clearly 
established, there will still remain eases in which the child mU8f he 

sacrificed in the best interests of the mother. Symphysiotomy should, 
however, do away with Cesarean section on the relative indication, and 
should relegate this more dangerous procedure where it belongs, to the 
realm of operations demanding absolute indications." 

Taking the general consensus of opinion at the present day, it may 
be said that symphysiotomy is indicated : (1) In simple flat pelves with 
a conjugate vera between 7 and 9 cm., 2.6-3.1 inches. (2) In gener- 
ally contracted pelves with a conjugata vera between 8.2 and 10 cm., 
3.2-3.9 inches. These rules presuppose that the head of the child is 
of normal size. Others, with Jewett, find an application for symphy- 
siotomy. (3) In mento-posterior face presentations which are irre- 
ducible or impacted. (4) In cases of impaction in occipito-posterior pres- 
entations, with a conjugate below 9 cm., 3.5 inches; version and the 
employment of the forceps are here more dangerous to mother and child 
than symphysiotomy. 

Living, viable children may be secured in simple flat pelves with a 
conjugate not less than 7 cm., 2.7 inches, and in generally contracted 
pelves not less than 7.5 cm., 2.9 inches, by the induction of premature 
labor. This operation is to be preferred in suitable cases. But when 
the time for it has gone by in cases in which the conjugate is not under 
7 cm., 2.7 inches, in simple flat pelves of 8.2 cm., 3.2 inches, in 
generally" contracted pelves that are so small that version or forceps 
cannot be entertained, the choice naturally lies between symphysiotomy, 
Cesarean section, and embryotomy. On statistical grounds the first 
should be preferred. The maternal mortality from Csesarean section is 
much greater than that from symphysiotomy. The tables of cases 
operated upon in this country, by various surgeons show a maternal 
mortality of almost 33 per cent., and an infant mortality of 13 per 
cent., in Cesarean section. Symphysiotomy is contraindicated in cases 
where the sacro-iliac joints are ankylosed. 

Briefly, then, the operation, as has been said, occupies a midpoint 
between Cesarean section and those less heroic measures — forceps, ver- 
sion, and the induction of premature labor. Its chief rival in cases of 
the same degree of pelvic narrowing may be said to be embryotomy. 
In the smallest pelves it cannot in any way take the place of Caesarean 
section, but, as Leopold has said, it may rightfully, in many cases, be 
substituted for Cesarean section on the relative indication, in Avhich 
also the delivery of a living, viable child is the aim in view. It should 
replace perforation of the living child as much as possible. 

Wehle sums up the indications for the operation in a few words : 
" It should be done in all cases where the child's head does not engage 
at the inlet, and where, according to our best knowledge, nothing re- 
mains to us but to perform perforation on a living child, provided the 



SYMPHYSIOTOMY. 735 

conjugate vera be between 7.5 or 7 to 6.5 cm., 2.9 or 2.7 to 2.5 inches. 
Conjugates above these limits belong to the other operations mentioned 
above. With conjugates below them there remains only embryotomy 
or Cesarean section. The woman should be free from infection and the 
pelvis should not be ankylosed. The child should be proved to be 
alive before the operation is begun. The soft parts should be prepared 
for the passage of the child." 

Rationale of the Operation. As has been said, the operation depends 
for its success upon the lengthening of the conjugate and the general 
enlargement of the area of the superior strait. The consequent engage- 
ment of the head plays no inconsiderable part in the further widening 
of the passage. When the pubic symphysis, together with the subpubic 
ligament, is divided and the pubic bones are separated from each other, 
they not only move outward from the median line, but also downward 
in a direction toward the feet. This is due to the fact that the axis of 
rotation at the sacro-iliac joints is not parallel to the long axis of the 
body, but runs from without inward and from above downward. 

This peculiarity of rotation has been well explained by Wehle, who 
compares the separation of the pelvic halves very aptly to the opening 
of a pair of double doors. Should the doorposts be vertical and the 
axis of rotation vertical, the under surface of the doors, when opened, 
will describe a plane perpendicular to the axis of rotation and tangen- 
tial to the earth's surface, the lower outer angle of the door neither de- 
scending from nor approaching the floor ; but should the doorposts be 
set at an angle from above downward and inward toward each other, 
then the doors, when opened, will still describe a plane perpendicular 
to the axis of rotation, but directed in each case from within outward 
and downward. The downward movement of the pubic bones also, 
with the accompanying nutation of the sacrum, of itself increases the 
length of the conjugata vera. The knowledge of this fact has been 
utilized in the well-known postural method of lengthening the brim 
conjugate by means of forced extension of the thighs. 

A separation of 3 cm., 1.1 inches, causes a descent of 2 cm., 0.7 inch, 
and the foetal head pressing upon the ends of the separated bones drives 
them still further downward. Another important thing to keep in 
mind is the fact that the anterior prominent part of the child's head, 
which in the majority of cases is one or other of the parietal promi- 
nences, is received in the space between the sundered bones. We see, 
then, that the canal for the passage of the child is rendered larger in 
three ways : (1) by separation of the ends of the bones, (2) by down- 
ward movement of the ends, and (3) by the accommodation of a prom- 
inent part of the child's head in the interpubic space. 

Technique of the Operation. The woman should be prepared as for 
an abdominal section. The pubic hair should be carefully shaved, and 
all parts in the neighborhood of the field of operation rendered as asep- 
tic as possible. The bladder should be empty. The operation is best 
delayed, when consistent with safety, until the birth canal has been pre- 
pared by nature as far as possible for the passage of the child. The 
cervix ought to be well dilated and the vagina should be of ample 
size. All these conditions are, however, not always obtainable. Should 
the vagina be long and narrow and relatively undilatable, serious lacer- 



736 



OBSTETRIC SURGERY. 



ations may be Looked for, and the danger to the child's life is much 
increased. 
The patient is placed upon her back on the table, with the thighs 

flexed and somewhat everted. This position can be maintained by 

mean- of a suitable leg-holder. Two assistants must steady the thighs 

and prevent undue reparation alter section of the symphysis. The 

exact situation of the symphysis should be determined, and should be 

indicated by a mark, 1 and it is advisable to draw a transverse line 
showing the situation of the subpubic ligament, which can usually be 

easily detected by the finger below or to one side of the clitoris. All 
assistant introduces a full-sized metallic catheter into the urethra. This 
is depressed as a whole, carrying with it the urethra out of the way of the 



Fig. 432. 



Fig. 433. 





Preliminary incision of the outer cover- 
ing between the recti with the cutting sur- 
face of the scalpel. (Farabeuf.) 



Extending with scissors the opening 
made by the scalpel. (Farabeuf.) 



knife ; the catheter serves also at the same time to keep the bladder empty. 
An incision is made beginning about 3 cm., 1^- inches, above the sym- 
physis and extending downward about three inches to the clitoris. The 
edges of the wound are separated by retractors, and with a few touches 
of the knife the linea alba is laid bare. (Figs. 432 and 433.) When 

1 A fine camel's-hair brush dipped in tincture of iodine or a solution of silver nitrate 
serves the purpose. 



SYMPHYSIOTOMY. 



737 



Fig. 434. 



the exact position of the symphysis cannot be readily determined, it is 
well to make gentle traction on the clitoris, the suspensory ligament of 
■which is attached to this point and can be made to serve as a guide. 
The next step is to separate the suspensory ligament of the clitoris, 
taking care not to wound the dorsal vessel, and to draw the clitoris 
down and out of the way, until the lower surface of the arch of the 
pubes is brought into view. By careful dissection the upper part of 
the symphysis is next exposed. A finger is then inserted between the 
recti muscles, and the symphysis is freed posteriorly, the tissues being 
pushed away from it. A broad, flat, grooved director or guard, strongly 
bent on the flat, is then inserted under guidance of the finger behind 
the symphysis, either from above downward or from below upward. 
(Figs. 435 and 436.) The function of this guard, 
which should be kept close to the symphysis, is to 
protect the tissues behind it from injury. The sec- 
tion of the symphysis may then be made either from 
within outward (Fig. 437), or, as Farabeuf advises, 
from without inward. Farabeuf uses a short, thin 
knife. (Fig. 434.) The external ligamentary tissues 
are first divided, then the periosteum, and finally the 
cartilage. The periosteum should not be stripped off 
the bone, except for a very short distance. Other 
methods of dividing the symphysis may be preferred. 
After laying bare the joint and opening the linea alba 
between the recti muscles a thin, probe-pointed, nar- 
row-bladed bistoury, passed downward on a finger 
as a guide through the abdominal incision, may be 
employed to sever the joint, the cut being made from 
behind forward. Galbiati's knife, or Harris's modi- 
fication of this instrument, may be used, instead of a 
bistoury. Any bleeding is controlled, and a pro- 
visional dressing of sterilized gauze is packed into and over the wound. 

Avers prefers the following subcutaneous method of dividing the 
symphysis pubis, and reports four successful cases. The procedure is 
somewhat as follows : The clitoris having been raised from the symphy- 
sis, a narrow, sharp-pointed scalpel is passed beneath it through the 
mucous membrane from below upward, in the line of the symphysis, to 
within about half an inch of the upper border of the pubes. The 
tissues of the joint are then cut through with a straight, blunt-pointed 
bistoury. In order that the bladder and urethra should not be injured 
during the procedure they are pushed to one side by means of a sound ; 
at the same time a finger in the vagina controls the blunt point of the 
bistoury while the tissues of the joint are being divided. 

Authorities differ as to whether or not forcible separation of the 
ends of the symphysis should be made. Some French authors, not- 
ably Farabeuf, advise that it be done at once, thus preventing need- 
less compression of the child's head. It would seem more reasonable, 
with Caruso, to support the hips by a sterile bandage and allow the 
process to go on more slowly. This plan is attended with less risk of 
serious laceration of the birth-canal and more nearly approaches the 
conditions attending a normal labor. The pubic bones should not be 

47 



Knife of Farabeuf. 



738 



OBSTETRIC SURGERY, 



allowed to separate further than 6.5 <>r 7 cm., 2.')-2. 7 inches; if this 
limit be not exceeded, do greal harm can be done at the Bacro-iliac 
joints. 

Ii must be kept in mind that while the separation may be within 

these limits, it may he due entirely to the downward and outward 
movement of one side, the other side not partaking in the rotation upon 
the sacral axis. The danger in allowing a larger amount of separation 

than 7 em., 2.7 inches, lies in the fact that the anterior ligaments of' 
the saero-iliac joints and the tissues in the immediate neighborhood may 
be very extensively ruptured. A small amount of laceration in these 

Fig. 435. 




Introduction of the finger and of the grooved guard by the suprapubic route. (Farabeuf.) 



tissues, as has been said, does no harm. If a separation of 7 cm., 2.7 
inches, or thereabouts is produced, and if this has been accomplished at 
the expense of one sacro-iliac joint, serious disruption may ensue in this 
joint, although the total amount of separation at the symphysis be well 
under the limit. To guard against this the operator should attend per- 
sonally to the separation at the pubes, and see that both ossa innominata 
are equally and gently rotated outward. Should one be rotated further 
out than the other, the situation can readily be detected by observing 
that one pubic end is lower than the other, whereas they should both 
be on the same imaginary line drawn perpendicularly to the long axis 
of the body. Care must be taken, during the passage of the child 
through the pelvis, that the structures anterior to the birth-canal be 



S YMPH YSIO TOM Y. 



739 



protected with due care, especially if any further operative procedures 
with the forceps or version be resorted to. It must be remembered 
that the posterior structures have the support of the sacrum, the coccyx, 
and the levator ani, but that those situated anteriorly have practically 
lost their only support. 

During delivery it is well to protect the field of operation, more espe- 
cially the incision and the immediate neighboring parts, from possible 
infection. This can best be done by packing either plain sterilized gauze 



Fig. 436. 




The grooved guard passed behind the symphysis, employed to protect the vessels and organs from 
the knife during the incision. (Farabeuf.) 



or iodoform gauze into and around the wound. This dressing can be re- 
tained in position by a firm, sterile canton-flannel binder. In fact, this 
procedure serves several other ends. The gauze packing in the wound, 
while stopping oozing, or even more active bleeding, gives at the same 
time considerable support of a yielding character to the bladder, urethra, 
and anterior structures. The flannel binder serves to support the ossa 
innominata, and while preventing the divided bones from separating 



TKi 



OBSTETRIC SURGERY 



Fio. r,7. 




Symphysiotomy. The division of the symphysis is accomplished (1) by section between the 
recti muscles, to sever as far as possible the hard, creaking bundles of the fibrous covering, and to 
trace in front a line correspondingto the groove of the guard, which is held firmly against the ridge 
corresponding to the articulation behind. (2) By means of a short, narrow blade with a rounded 
extremity the operator then cuts through the symphysis from above downward, with the cutting 
edge of the blade directed forward and under the protection of the grooved guard. (Fakabeuf.) 

too far, allows them to give enough to permit the passage of the 
child. 



SYMPHYSIOTOMY. 

Fig. 438. 



741 




Mode of introduction of sutures. These should be of strong silk, and should be inserted from 
the outer borders of the longitudinal bands, keeping close to the bones. It is best to begin on the 
right side, which presents the greatest difficulty. (Farabeuf.) 



Fig. 439. 




Tying the sutures, while the bones are held in place by Farabeuf 's forceps. (Farabeuf.) 



742 



OBSTETRIC SURGERY. 



After the completion of labor the wound should be dosed. It is a 
matter Btill under discussion whether it is better to wire the ends of the 
divided symphysis together, as is done in the case of compound fract- 
ures in the long hones, or whether Borne form of suturing the ends 
together through their firm fibrous outer covering is not the better plan. 
Our opinion is decidedly in i'avor of the latter procedure. 

Three or four stout silk, silver-wire, or stout silkworm-gut sutures 
are passed across the gap between the hones, taking in the margins of 
the muscular insertions and all the fibrous tissues down to and includ- 
ing the periosteum. These are tied in the median line, cut short, and 
buried, (Figs. 438 and 439.) The superficial wound may be closed in 
a variety of ways. It is important to dispense with drainage, if this 
be possible. If the bladder be ruptured, it should be sutured, and care- 
ful after-attention given to see that the viscus does not become dis- 
tended and allow the occurrence of extravasation of urine. In such 
case the complete or incomplete closing of the external wound must be 
left to the judgment of the operator. 

Fig. 440. 




Avers' symphysiotomy hummock (empty), showing arrangement of canvases, bedpan, etc. 



After the wound has been dressed aseptically the next indication is to 
put the parts at rest, and so to retain the ends of the bones in apposi- 
tion that the sutures may not be subjected to undue strain. This indi- 
cation is a difficult one to meet, as is shown by the numerous expedients 
that have been devised for the purpose. Pinard uses a gutter-shaped 
bed or mattress, and places cushions under the lateral halves of the 
body. Jewett and others adopt practically the same method, using an 
ordinary, rather hard mattress and keeping the patient on two firm 



SYMPHYSIOTOMY. 



743 



cushions placed under the lateral halves of the pelvis and extending 
nearly to the shoulders. 

The difficulty can often be solved by placing the patient on a moder- 
ately firm bed, and by strapping the pelvis with strips of adhesive 
plaster. This is the old treatment for fracture of the pelvis, and is still 
employed in this surgical accident. Lateral sand-bags, reaching from 
the axilke to just above the external malleoli, should also be employed. 

When the bedpan is used the greatest care should be exercised by 
the nurse to see that no movement on each other of the anterior ends 
of the bones is permitted. It is best to have ready a strong, intelligent 
assistant to support the pelvis and gently lift the buttocks while the 
nurse slips the vessel beneath. 

An excellent apparatus for maintaining coaptation of the pubic 
bones after symphysiotomy is Ayers' hammock-bed. This consists of a 
canvas stretcher supported as shown in Figs. 440 and 441. The 

Fig. 441. 




Avers' symphysiotomy hammock, showing patient. Pelvis is supported by upper poles. 
Lower poles and hammock support head, chest, and limbs, and is adjusted to level of upper 
hammock. 



stretcher may be made more or less trough-shaped by the adjustment at 
less or greater distance apart of the poles on Avhich it hangs. A canvas 
sling wide enough to reach well above and below the pelvis is sus- 
pended by its ends from a second pair of poles above the first. AVhen 
adjusted for use the loop of this pelvic sling reaches the stretcher. The 
patient rests with her pelvis in the loop of the sling, while the remainder 
of her body is supported by the stretcher. It will be seen that the 
pubic bones are held firmly in apposition by the action of the sling, 



7 1 I OBSTETRIC SURGERY. 

while the upper portion of the body and the lower extremities Lie < i- 

fortably upon the b1 reteher, 

In the Dresden clinic patients are provided with a pelvic support, 

and are allowed to gel lip after three week-. It would seem that this 

i- too early to allow the patient to assume the erect position ; in any 
case, it is wiser to keep her fully >i.\ weeks in bed, treating the case as 

one would a pelvic fracture or a fracture of the femur. The pelvic 
support should not he discarded tor several week- after the woman 
leaves her bed. 



INDEX 



ABDOMEX, antepartum examination of, 
213 
contour of, in pregnancy, 133 
enlargement of, in ectopic gestation, 371 
examination of, in accidental hemor- 
rhage, 506 

in placenta prsevia, 500 

in pregnancy, 133 

in transverse presentation, 464 

in uterine rupture, 492 

value of, 219 
general tenderness of, in ectopic gesta- 
tion, 366 
palpation of, in pregnancy, 134 
pendulous, with prolapsus funis, 481 
preparation of, for coeliotomy, 724 
size of, in pregnancy, 134 
strise of, 1 34 
tenderness of, in puerperal endometritis, 

587 
value of inspection signs, 134 
Abdominal binder, 246 

in accidental hemorrhage, 507 

in placenta prsevia, 505 

in post-partum hemorrhage, 51 1 
examination for abnormal conditions, 

219 
incision for Csesarean section, 725 

indication for, 721 
intrafcetation, 474 
section in rupture of uterus, 494 
stalk, 87 

wound, closure of, 728 
Abortion, actual, treatment of, 346 
cardiac disease a cause of, 544 
caused by certain drugs, 337 
complete, pathology of, 340 
criminal, 335, 641 
definition of, 335, 641 
diagnosis of, 343 
embryonic, 335 
etiology of, 336 
foetal, 335 

causes of, 338 
frequency of, 335 
habitual, 338 

treatment of, 345 
in diabetic women, 543 
induction of, 641 
incomplete, 340 

by dilatation of cervix, 649 

Cohen's method, 647 

electricity in, 645 

Hamilton's method, 646 



Abortion, induction of, indications for, 642 
in vomiting of pregnancy, 391 
Kiwisch's method, 645 
Krause's method, 646 
Scanzoni's method, 645 
Scheel's method, 648 
Tarnier's method, 646 
local causes of, 338 
maternal causes of, 336, 337 
method of inducing, 643 
missed, 352 
ovular, 335 

paternal causes of, 336 
pathology of, 339 
premonitory signs of, 342 
prognosis of, 344 
prophylactic treatment of, 345 
symptoms of, 341 
threatened, treatment of, 346 
time of occurrence of, 336 
tubal, 362 
"Abscess de fixation," 605 

mammary, in new-born, 618 
of broad ligament, 588 
parametritic, treatment of, 602 
Abscesses, tubal and ovarian, treatment of, 

602 ^ 
Acardiacus as a cause of difficult labor, 480 
Accouchement force, 504, 535 

indication for, in cardiac disease 

complicating pregnancy, 546 
in placenta prsevia, 504 
in spasmodic contraction of uterus, 
407 
Acetic acid in post-partum hemorrhage, 512 
Acetone, present in eclampsia, 519 

in urine during puerperium, 253 
Acini of mammary gland, 68 
Adipocere formation of foetus, 375 
After-pains, 209 
Agalactia, 553 
Air hunger, 500 

infection from, 577 
injection into intestine, 140 
Albumin in urine, following labor, 253 

test for, 211, 395 
Albuminuria, 394 

a cause of puerperal insanity, 556 
diagnosis of, 395 

favored by abdominal pressure, 1M 
frequency of, 126 

and etiology of, 395 
in eclampsia, 518, 523 
in triple pregnancy, 479 

(745) 



746 



I SI) EX. 



Albuminuria in twin pregnancy, 176 

prognosis and treatment of, '">'. u > 
Alcohol in post-partum hemorrhage, 512 

in puerperal Infection, 602 
Alcoholism, paternal, a cause <>f abortion, 

336 
Alimentary tract, development of, 105 
Allantois, development of, 87 
Amenorrhoea, causes of 129 
Amnion, anomalies and diseases of, 300 

development of, 86 

dropsy of, 301 

in ectopic gestation, 362 

rupture of, diagnosis of, 300 
Amniotic bands, 303 

fluid, changes in character of, 303 
deficiency of, 300 
excess of, 481 
in version, 680, 683 
removal of, to induce abortion, 648 

sac, pressure of, on cervix, 198 
Ampulla of rectum, 36 
Ampullae of lacteal ducts, 69 
Anaemia, acute, signs of, 500, 510 
treatment of, 508 

cerebral, a cause of eclampsia, 519 

contraindication to nursing, 272 

in post-partum hemorrhage, treatment 
of, 513 

in pregnancy, 394 
Anaesthesia for removal of adherent pla- 
centa, 653 

in repair of vaginal lacerations, 633 

in reposition of inverted uterus, 488 

in transverse presentations, 367 

in version, 680, 685 

obstetric, 238 

profound, post-partum hemorrhage 
from, 509 

to relax uterus, 493 
Anaesthetic in face presentations, 451 

in forceps operation, 662 

in occipito posterior cases, 447 
Anaesthetics, administration of, 238 

choice of, 238 
Anal canal, 36 

Anatomy of female pelvic organs, 17-64 
Anencephalus, 472, 479 
Anorexia in pregnancy, 387 
Anterior commissure, 18 
Anteversion of uterus, 439 
Antihelix, development of, 105 
Antisepsis, chemical, 229 

choice of methods of. 230 

effect of, on puerperium, 585 

mechanical cleansing, 228 

obstetric, 227 
Antiseptic precautions, 231 
for the nurse, 232 
in version, 680 

preparation in vaginal examination, 222 
of obstetric patient, 232 
Antitoxin, tetanus, 623 
Antitragus, development of, 105 
Anus, anatomy of, 25 

congenital malformations of, 609 

development of, 108 



Anus vaginalis, 444 

Aorta, development of, 94 
maternal, pulsation of, 138 

Aortic bulb, 92 

Apoplexy, diagnosis from eclampsia, 522 

Appendages, foetal, anomalies and diseases 

of, 299 
Aqueduct of Sylvius, 99 
Aqueous humor, development of, 102 
Arbor vita? uterini, 48 
Arch, branchial, 106 

visceral, 106 
"Area vasculosa" in embryonic circulation, 

90 
Areola, 66 

primary, 130 
secondary, 132 
wrinkling of, 132 
Armamentarium, obstetric, 227 
Arms, displacement of, in breech presenta- 
tion, 456 
upward displacement of, in breech pre- 
sentations, treatment of, 459 
upwardly displaced, release of, when 
head is below brim, 460 
Arsenic in puerperal insanity, 561 
Arteria centralis retinae, 102 
Arterial tension in pregnancy, 125 
Arteries, carotid, development of, 94 
hypogastric, development of, 95 
iliac, development of, 95 
Ascites, diagnosis from hydramnios, 302 
differential diagnosis from pregnancy, 

148 
foetal, obstructing labor, 474 
Asepsis of the hands, 230, 596 

permanganate method, 231 
Asphyxia in new-born child, causes of, 613 

treatment of, 613 
Aspiration in spina bifida, 608 
Asynclitism, 203 
Atelectasis, 617 
Atresia of cervix, 437 
Atropia, oleate of, indication for, 552 
Auditory vesicle, 104 
Auricular canal in embrvonic circulation, 

92 
Auscultation of abdomen in pregnancy, 136 
Auto-intoxication in eclampsia, 520 

-transfusion, 513 
Axis, parturient, 174 

-traction forceps, 676 

indication for, 671 
with ordinary forceps, 670 



BACILLUS aerogenes capsulatus in puer- 
peral infection, 566 
coli communis in puerperal infection, 

565 
diphtheria? in puerperal infection, 566 
of Doderlein, 43 
sepsis in puerperal infection, 567 
typhosus in puerperal infection, 567 
Bacteria in puerperal infection, 563 
Bags, dilating cervical, method of filling, 
504 



INDEX. 



747 



Ballotteruent in ectopic gestation after the 
fourth month, 372 
external, 135 
in placenta praevia, 500 
internal, 144 
BanuTs ring, 493 
Barley water in diluting milk, 279 
Barnes' bags, 503, 646 

indication for, 456 
in dilatation of cervix, 649 
Basiotribe, Tarnier's, 714 
Bath of new-born child, 270 
Bathing in pregnancy, 154 
Benzoin, tincture of, for sore nipples, 549 
Birth palsies, 610 
Births, plural, 476 

complex cases, 477 
Bladder, anatomy of, 37 

care of, following operations on pelvic 

floor, 636 
conditions of, obstructing labor, 444 
development of, 111 
dilatation of, in foetus, 474 
distended, retention of placenta from, 

652 
distention of, 444 
after labor, 253 
in foetus, 474 

secondary hemorrhage from, 516 
simulating pregnancy, 149 
evacuation of, in second stage of labor, 

652 
injuries to, from forceps operation, 661 
irritability of, in pregnancy, 130 
maternal, distention of, 136 
of new-born child, 268 
relation to parturient canal, 173 
rupture of, in symphysiotomy, 742 
shape of, 39 
Blastoderm, development of, 79 
Blebs in puerperal pyaemia, 575 
Blood, amount of lost, in normal labor, 209 
changes in, during pregnancy, 124 
derivation of, 97 
diseases of, an indication for induction 

of abortion, 642 
of new-born child, 267 
Bloodvessels, foetal, lesions of, 331 
Boiling as a method of sterilization, 228 
Bougies in induction of labor, 650 
Bowels after labor, 253 

care of, during puerperium, 258 

following operation on perineum, 

636 
in pre-eclamptic state, 525 
irrigation of, in anaemia, 514 
in eclampsia, 532 
Brachial plexus, injuries to, in forceps 

operation, 661 
Brain, development of, 98 
fore-, 98 
hind-, 98 

injuries in instrumental delivery, 657 
mid-, 98 
Breasts. See Mammary glands, 
anomalies and diseases of, 547 
care of, in pregnancy, 154 



Breasts, changes in, in ectopic gestation after 
fourth month, 370 
enlargement of, during pregnancy, 130 
evidence of previous pregnancy in, 152 
normal structure of, 547 
veins of, 130 
Breech deliveries, paralysis sometimes fol- 
lowing, 611 
delivery in flat pelvis, 422 
impaction of, treatment of, 458 
non-engagement at the brim, manage- 
ment of, 457 
presentation, external version in, 681 
Bregma. See Fontanelles. 
Brim, pelvic, 162 

landmarks of, 162 
plane of, 165 
Bromides in puerperal insanity, 561 
Bronchi, development of, 109 
Broncho-pneumonia, infectious, 589 
Brow presentation, frequency and etiology 
of, 452 
version in, 700 
Bruit, infantile, 609 
Buckmaster's sling, 227 
Bulbs of vagina, 28 



CAECUM, development of, 108 
Caesarean section, 722 

absolute indications for, 723 
after-treatment of, 728 
for carcinoma of cervix with preg- 
nancy, 442 
for fibromyoma of uterus with 

pregnancy, 441 
for tumors of vagina obstructing 

_ labor, 443 
history of, 722 
in bicornate uterus, 437 
indications for, 445, 493, 508, 704 
in cardiac disease complicating 
pregnancy, 546 
in eclampsia, 528 
in flat pelvis, 424 
in ''funnel-shaped" pelvis, 418 
in kyphotic pelvis, 435 
in malacosteon pelvis, 428 
in obliquely contracted pelvis, 425 
in scoliotic pelvis, 436 
in spasmodic contraction of uterus, 

407 
in tumors of pelvis, 432 
in vaginal enterocele obstructing 

labor, 443 
mortality in, 706 
operation, 724 

instruments for, 725 
points in technique of operation, 729 
preparation for, 724 
relative indications for, 723 
scar from, 490 

time for performance of, 724 
Calculus, vesical, dystocia from, 444 
Canal of Xuck, anatomy of, 61 

parturient, enlargement of, in sym- 
physiotomy, 735 



748 



INDEX. 



( apu( Buooedaneum, 207 
absence of, 329 
in brow presentation, 452 
in face presentation, 1 19, 1"»1 
Carbolic solution as an antiseptic, 229 
Carbon dioxide, excess of, in blood a cause 

of labor, L94 
Carbonic-acid gas, increase of excretion of, 

in pregnancy, 126 
Carcinoma of cervix obstructing labor, 442 

of uterus, hemorrhage from, 516 
Cardiac disease complicating pregnancy, 5 I ! 
symptoms and treatment 
of, 545 
in pregnancy, hygienic treatment 
of, 545 
lesions an indication for induction of 
abortion, 642 
Carnnculse myrtiformes, 23, 248 
Casein, comparison of, in human and cow's 
milk, '-'77 
eflect of excess of, in milk, 286 

of sterilization upon, 283 
method of reducing, 280 
Catharsis in eclampsia, 532 
Catheterization following repair of vaginal 
lacerations, 636 
indication for, following labor, 257 
method of, 258 
Catheters, care of, 639 
Cauda equina, development of, 101 
Cavity of Retzius, anatomy of, 38 
Cephalhematoma, 267, 610 
treatment of, 610 
with large foetus, 470 
Cephalic prominence, foetal, location of, 216 
Cerebellum, development of, 99 
Cerebral vesicles, primary, 98 
Cervical canal, micro-organisms of, 579 

lacerations, reasons for immediate repair 
of, 640 
Cervix, atresia of, obstructing labor, 437 
carcinoma of, 442 
danger of rapid dilatation of, 530 
dilatation of, in eclampsia, 528 
in forceps operations, 663 
in labor, 198 
in uterine inertia, 403 
to induce abortion, 649 
impaction of, 438 
imperfect dilatation of, 536 
incisions of, in rapid delivery, 531 
injuries to, from forceps operation, 661 
lacerated, immediate repair of, 639 
laceration of, method of operation for, 

640 
manual dilatation of, in placenta praevia, 

504 
purplish hue of, in pregnancy, 141 
rigid, treatment of, before rapid de- 
livery, 538 
rigidity of, in eclampsia, 531 

in spasmodic contraction of uterus, 

407 
obstructing labor, 437 
treatment, 438 
rings of, 199 



< erviw softening of, l 1 1. 198 

undiluted, ;i contraindication to use of 

forceps, 859 

uteri, anatomy of, 46 

during firsl Btage of labor, 201 
pregnancy, 122 

mucous follicles of, 123 
Champetier de Ribes'e 1 »:t lt, indication for, 
156 

ballon, 503 
Child, asphyxia of, following forceps de- 
livery, 662 

care of, 244 

examination of, at birth, 245 
growth of, 269 

injuries to, in forceps operation, 661 
mortality of, in breech cases, 455 
new-born, anatomy of, 265 
diseases of, 618 
examination of, 270 
heart of, malformations of, 608 
injuries to bones and muscles of, 
610 
during birth, 609 
malformations of, 607 

rectum and anus, 609 
management of, 269 
physiology of, 267 
weight of," 269 
nursing of, 260 
Chill in puerperal infection, 587 
Chloasma uterinum, 152 
Chloral hydrate in eclampsia, 527 
in puerperal insanity, 561 
in rigidity of cervix, 438 
in uterine inertia, 405 
Chlorinated soda, antiseptic solution, 229 

for sterilizing hands, 231 
Chloroform, administration of, in labor, 239 
in eclampsia, 527 
indication for, 545 
in version, 685 
Chorion, degeneration of, 304 

pathology, etiology, and symptoms, 

305 
treatment, 306 
diseases of, 304 
frondosum, 88 
in ectopic gestation, 362 
laeve, 88 

malignant disease of, 304 
primitive, 85 
Choroid, development of, 102 
Choroidal fissure, 102 
Circulation, changes in, at birth, 97 
during pregnancy, 124 
disorders of, in pregnancy, 393 
embryonic, 90, 97 
foetal, 90 

primitive embryonic, 93 
utero-placental, 89 
Clavicle, fracture of, at birth, 610 
Clavicles, severing of, in embryotomy, 716 
Clitoris, anatomy of, 24 
development of, 115 
Clothing in pregnancy, 153 
of new-born child, 270 



INDEX. 



749 



Coagulation ferments in eclampsia, 519 
Cochlea, development of, 104 
Colic in new-born child, 625 

diagnosis of, 626 
treatment of, 626 
Colostrum, 132. 626 

action of, on child, 255 
Colpeurynter, 645 

in cervical dilatation, 651 
Colpocystocele, 444 
Columnae vaginae, 43 
Conjunctivitis in new-born child, 621 
Consciousness, loss of, in eclampsia, 518 
Constipation in pregnancy, 155, 392 
Contraction ring of uterus obstructing de- 
livery, 700 
Contractions, uterine, 135, 144, 157, 195 
cause of pain, 200 
force of, 200 
strength of, 158 
Convulsions, eclamptic, treatment of, 527 

puerperal. See Eclampsia. 
Cord, injury to, in forceps operation, 661 
ligation of, 245, 269 
prolapse of, 455 

treatment of, 270 
with tumors of uterus, 441 
umbilical, about the neck, complicating 
version, 701 
anomalies of, 310 
asphyxia from compression of, 613 
coil of, about the neck, 310, 701 
compression of, 469 
danger of traction on, 486, 652 
insertion of, 310, 499 
interlacing of, in twin births, 478 
knots in, 311 
length of, 310 
position of, 310 
prolapse of, 481 

reposition of, instrumental method, 
483 
manual method, 483 
shortness of, 469 

a cause of inversion, 486 
diagnosis of, 470 
treatment, 470 
strength of, 470 

treatment of, in twin births, 476 
Cords of Pfluger, 113 
Cornea, development of, 102 
Corpora quadrigemina, development of, 99 j 
Corpuscles, colostrum, 273 

red, number and size of, at birth, 267 
Corpus luteum, 252 

anatomy of, 60 
spurium, 75 
verum, 75 
Cranial bones, fracture of, in infant, 610 
Cranioclast, 713 
Craniotomy, 710 

and symphysiotomy, 719 
indication for, 493, 508, 703 
method of operating, 710 
on after-coming head, 717 
Cranium of new-born child, 265 
Cream, gravity, disadvantages of, 281 



Crede's method of expelling placenta, 598 
Creolin, advantages of, 685 

solution as an antiseptic, 229 
Cristse vagina?, 43 
Crura cerebri, development of, 99 
Crushing operations, 714 
Cul-de-sac of Douglas, 37 

anatomy of, 44 
Cultures of bacteria from uterus, 592 

from vagina, 582 

from vulva, 584 
Curettage, description of operation, 350 
Curette in puerperal endometritis, 599 
Cyanosis neonatorum, 98 
Cystocele, 444 

Cyst, ovarian, resembling pregnancv, 147, 
148 



DEATH, foetal, diagnosis from asphyxia, 
617 
of large foetus, indication for embry- 
otomy, 708 
Decapitation, 714 

-hook, Braun's, 714 

Zweifel modification of, 715 
indication for, 480 
in transverse presentations, 469 
Decidua, diseases of, 299 

a cause of abortion, 338 
in ectopic gestation , 360 
imperfect development of, 300 
menstrualis, 73 
reflexa, 88 
serotina, 88 
vera, 87 

loosening of, in labor, 194 
Deformities, pelvic, detection of, 220 

in different races, 172 
Delivery after embryulcia, 462 

completion of, after version, 693 
gradual, following version, 698 
rapid, bimanual method, 538 

dangers of, with rigid cervix, 539 
in pre-eclamptic state, 526 
methods of, in eclampsia, 528 
recent, positive signs of, 263 
probable signs of, 264 
uncertain signs of, 264 
Dental caries in pregnancy, 392 
Dermoid cyst, 330 
Diabetes complicating pregnancy, 543 

treatment, 543 
Diameter of Baudelocque, 220 
bisischial, of pelvis, 170 
diagonal conjugate, measurement of, 

223 
external conjugate, 169, 220 

in spondylolisthetic pelvis, 430 
foetal, bimastoid, 178 
biparietal, 178 
bitemporal, 178 
cervico-bregmatic, 178 
fronto-mental, 178 
occipito-frontal, 178 

-mental, 178 
suboccipito-bregmatic. 178 



750 



ini>/:.\. 



Diameter, foetal, Buboocipito-frontal, 178 
intercristal, measurement of, 221 
pelvic, external conjugate, l<» ( .', 220 
oblique, 170 
intereristal, 170, 221 
interna] oonjugate, measurement of, 

728 
interspinal, 170 
pubo-OOCCygeal, measurement of, 222 
B&cropubic, measurement of, 222 
transverse, measurement of, 222 

tine oonjugate, measurement of, 221, 223 

Diameters, external, of pelvis, 169 

in spondylolisthetic pelvis, 430 

of fetal head, 178 
Diaphoresis in eclampsia, 532 

in pre-eclamptic state, 525 
Diarrhiea in pregnancy, 392 
Diet in pre-eclamptic state, 524j 

in pregnancy, 153 

in preventive treatment of eclampsia, 
521 

in vomiting of pregnancy, 390 

mother's, while nursing, 272 
Digestion, changes in, during pregnancy, 125 

disturbances of, in pregnancy, 387 

following labor, 255 

of new-born child, 267 
Digestive juices at birth, 268 

organs during pregnancy, 155 
Dilatation of cervix, digital, 650 

of os uteri, rapid methods of, 540 
Dilator, Barnes's, in rigid cervix, 438 

for cervix, 649 
Diseases, constitutional, affecting placenta, 

506 
Dislocation of femora affecting pelvis, 431 
Diuresis in eclampsia, 532 

in pre-eclamptic state, 525 
Douche, bichloride, death from, 601 

during puerperium, 599 

in puerperal endometritis, 600 

intra-uterine, indication for, 654 

in post-partum hemorrhage, 512 
in puerperal infection, 600 

vaginal, following repair operations, 
639 
use of, 581 
Drainage in Cesarean section, 729 
Dropsy, amniotic, dyspnoea from, 125 
Drugs for induction of premature labor, 650 
Duct, cystic, malformations of, 620 

galactophorous, 69 

of Gartner, 113 

of Miiller, anatomy of, 51 

Wolffian, 109 
Ducts, hepatic, development of, 109 

Miillerian, 111 

of Cuvier, 95 
Ductus arteriosus, 94, 267 

Botalli. See Ductus arteriosus. 

communis choledochus, development 
of, 109 
malformations of, 620 

venosus, 97 
Duties, final, of physician after labor, 246 
Dyspnoea during pregnancy, 125 



Dyspnoea in hydramnioe, :!01 
in pregnancy, 39 i 

from heart lesions, 645 
Dystocia, classification of, 399 

from anomalies of expellent forces, 
101 

of foetal development, 469 

of soft parts, 437 
from conditions of bladder, 444 

of cervix, 437 
from deficiency of expellent forces, 102 
from foetal anomalies and malpositions, 
1 I-". 
monstrosities, 479 
from malpositions of uterus, 439 
from pelvic deformities, 409 
from spasmodic contraction of uterus, 

406 
from tumors of abdominal and pelvic 
structures, 444 



EAR, development of, 104 
external, development of, 101 
middle, developmentof, 104 
Ecbolics, 643 

Eclampsia, causes of, exciting, 521 
of foetal death in, 522 
of maternal death in, 522 
predisposing, 521 
curative treatment of, 526 
defined, 517 
etiology of, 518 

frequency and symptomatology of, 517 
indication for use of forceps in, 660 
in twin pregnancy, 476 
methods for elimination of poisons in, 
532 
of rapid delivery in, 528 
pathology of, 521 
preventive treatment of, 523 
prodromal period of, 517 
prognosis of, 522 
stage of coma, 518 

of convulsions, 517 
of invasion, 517 
treatment of, 522 
Ectoderm, development of, 80 
tissues developed from, 81 
Ectopic gestation, 355 

after the fourth month, 369 

general considerations 
on treatment of, 381 
anomalous varieties of, 355 
concurrent with uterine gestation, 

385 
diagnosis of, 364 

after fourth month, 373 
differential diagnosis from abor- 
tion, 344 
earlv primarv rupture, treatment 

of, 377 
etiology of, 358 
extraperitoneal rupture, 367 
intraperitoneal rupture, 365 

treatment of, 377 
near full term, treatment of, 381 



INDEX. 



751 



Ectopic gestation, pathology of, 359 
pelvic pain in, 365 
repeated, 385 

secondary rupture, 368, 379 
sepsis in, treatment of, 379 
subperitoneal rupture, treatment 

of, 378 
symptoms of, 364 
treatment of, 376 

after rupture, 377 
before rupture, 376 
twin, 385 
utero-abd( 
vaginal incision in, 382 

in septic cases, 379 
with, foetus in abdominal cavity, 
treatment of, 383 
in unruptured tube, treat- 
ment of, 382 
subperitoneal, treatment 
of, 384 
Egg-albumin in milk foods, 287 
Embolism following induction of abortion, 

648 
Embryo, nourishment of, 88 

size of, at second month, 117 

at third month, 116 
stages in development of, 116 
Embryotome, Tanner's, 715 
Embryotomy, accidentally performed, 708 
choice of methods, 709 
contraindication to, 708 
defined, 708 
frequency of, 719 
indication for, 493, 700, 708 
in spasmodic contraction of uterus, 407 
or Cesarean section, 720 
precautions in, 721 
prognosis of, 709, 720 
reduction of trunk, 716 
relation of, to other procedures, 720 
unusual complications in, 718 
Embryulcia, 469 

for tumors of vagina obstructing labor, 

443 
in bicornate uterus, 437 
in breech presentations, 462 
indications for, 451, 458, 470, 478 
in flat pelvis, 424 
in funnel-shaped pelvis, 418 
in obliquely contracted pelvis, 425 
in tumors of pelvis, 432 
Eminence, ilio pectineal, 162 
Emotional influences in labor, 201 
Encephalocele, 607 
Endocarditis, foetal, 331 
Endometritis, chronic, adherent placenta 
from, 652 
diffuse decidual, 299 
"diphtheritic," 570 
during puerperium, 263 
gonorrhceal, 601 
mixed infection, 573 
puerperal, 570 

treatment of, 599 
putrid form, symptoms of, 587 
septic, 587 



Endometrium, formation of, after labor, 

251 
Enema, administration of, following opera- 
tions on perineum, 639 
Enemata in pregnancy, 155 
Enterocele, vaginal, 443 

treatment of, 443 
Entoderm, development of, 80 
tissues developed from, 82 
Epididymis, development of, 112 
Epiglottis, development of, 109 
Epilepsy a contraindication to nursing, 272 
diagnosis from puerperal eclampsia, 521 
Episiotomy, 242 

in oedema of vulva, 443 
Epoophoron. See Parovarium. 
Ergot a cause of uterine rupture, 491 

after removal of adherent placenta, 654 
ecbolic action of, 643 
in accidental hemorrhage, 508 
indication for, 546 
in placenta prsevia, 505 
in post-partum hemorrhage, 511, 512 
in puerperal infection, 601 
in uterine inertia, 406 
use of, in third stage of labor, 244 
Esbach's test for albumin, 211 
Esmarch mask, 685 
Eustachian tube, development of, 104 

< valve, 77, 266 
Evisceration, 717 

indication for, 475 
in transverse presentations, 469 
Evolution, spontaneous, in transverse pre- 
sentations, 466 
Examination, abdominal, in labor, 234 
method of, 138 
record of, 225 
antepartum, 212 

record of, 224 
bimanual, in ectopic gestation, 372 
in pregnancy, steps of, 128 
obstetric, objects of, 156 
preparation for, 133 
pelvic, during puerperium, 263 

method of, 140 
rectal, during labor, 597 
vaginal, 222 

during labor, 237 
in labor, 235 

frequency of, 235 
in uterine inertia, 404 
presence of mass in ectopic gesta- 
tion, 365 
record of, 225 
Exercise in pregnancy, 153 . 

Exhaustion from prolonged labor, a cause] 

of post-partum hemorrhage, 509 
Exomphalos, 475 
Exostoses deforming pelvis, 431 
Expelling powers in labor, 157 
Expulsion of foetus, mechanism of, 201 
Extraction following version, 695 
rapid, after version, 695 
mortality of, 697 
Extremities, development of, 115 
first appearance of, 116 






752 



INDEX. 



Eye, development of, 101 
Eyelids, development of, LOS 



FA< IE presentations, 448 
Abnormal conditions in, r> () 
combined version in, 682 
diagnosis from breech, 45fi 
mento-posterior, indication for 
symphysiotomy in, 7.'M 
Facial paralysis, from forceps operation, 661 
Painting in pregnancy, .* '>'.•:; 
Fallopian tubes, anatomy of, 52 
development of, 113 
fimbriae of, 55 
mucous lining of, 57 
nerves of, 64 
vessels of, 63 
Faiadism in birth paralyses, 611, 612 

for tardy involution, 2(53 
Fascia, anal, anatomy of, 34 
obturator, anatomy of, 30 
pelvic, anatomy of, 29-31 

vesical layer of, 30 
recto vesical, anatomy of, 30 

function of, 630 
superficial, of perineum, anatomy of, 27 
Fat, comparison of, in human and cow's 
milk, 277 
deficiency of, in milk, 286 
method of increasing, in milk, 280 
in milk, effect of sterilization on, 283 
Feces of the infant, 288 
Feeding, artificial, of infant, 276 
amount of, 287 
frequency of, 287 
forced, of infant, 288 
mixed, of infant, 276 
of new-born child, precautions in, 627 
substitute, of infant, 276 
Femur (foetal i, fracture of, in delivery, 696 
Fibroid, submucous, resembling pregnancy, 
144 
tumor of uterus resembling pregnancy, 
148 
Fibroma, uterine, secondary hemorrhage 

from, 516 
Fibromyoma of uterus obstructing labor, 
440 
treatment of, 441 
with pregnancy, diagnosis of, 441 
Filum terminate, 100 
Fimbria ovarica, 56 
Fissures of nipples, 548 
Flexion of foetal head in labor, 202 
Foetal anomalies, production of, 330 

appendages, anomalies and diseases of, 
299 
development of, 84 
death, 617 
development, anomalies of, obstructing 

labor, 469 
exhaustion an indication for use of 

forceps, 660 
head, abnormal occipito-posterior posi- 
tions of, 446 
approximate diameters of, 179 



Foetal head, bones of, 175 

changes in diameters of, in labor, 
180 

circumference of, 179 

compression of, with forceps, 867 

detached from trunk, delivery of, 
676 

determination of position of, pre- 
vious to forceps operation, 663 

diameters of, 1 78 

estimation of size of, prior to ap- 
plication of forceps, 658 
extension of, in labor, 204 
external rotation of, 206 
large, in eclampsia, 521 
lateral inclination of, in labor, 203 
moulding of, 207 

in fiat rachitic pelvis, 422 
in labor, 179 
obstetric anatomy of, 175 
occipito-posterior position of, 445 
palpation of, 215 
planes of, 179 
protuberances of, 177 
restitution of, in labor, 206 
rotation of, experiment of Dubois, 
203 
experiment of Edgar, 203 
size of, for application of forceps, 

659 
sutures of, 175 

unengaged, a contraindication to 
use of forceps, 659 
infection, 328 
movements, 135 

parts, impaction of, complicating ver- 
sion, 700 
palpation of, in abdominal exam- 
ination, 134 
pole, lower, palpation of, 214 
upper, palpation of, 215 
shock, 140 
Foetus, abnormalities of, contraindicating 
version, 700 
anomalies of, developmental, abrachius, 
316 
acardiacus amorphus, 312 
acephalus, 312 
acheilia, 316 
acormus, 312 
acrania, 312 
acromegalic, 324 
aglossia, 316 
agnathia, 314 
amelus, 316 
amyelie, 316 
aprosopus, 315 
apus, 316 
atresia?, 323 
cleavage, 320 

cranial and vertebral, 321 
intestinal, 322 
of chest and abdomen, 322 
of lips, jaw, and palate, 321 
vesical, 321 
club-foot, 323 
craniopagus, 324 



INDEX. 



753 



Foetus, anomalies of, cranioschisis, 321 
cretinisnius, 313 
cryptorchismus, 323 
cyclopia, 313 
dicephalus, 324 
diprosopus, 324 
dipygus, 324 
diverticula, 323 
diverticulum, Meckel's, 323 
dwarfs, 318 

dystopia? of separate organs, 325 
ectopia cordis, 322 

vesica? urinaria?, 322 
engastrius, 325 
epigastrius, 325 
epignathus, 325 
epispadias, 322 
fistula coli congenita, 321 
from arrested development, 318 
gastroschisis, 322 

genital organs, arrested develop- 
ment of, 319 
hare-lip, 321 
hemicrania, 312 
hermaphroditismus, 319 
hernia peritonealis congenita, 322 
hydrencephalocele, 321 
hypertrichiasis, 324 
ischiopagus, 324 
luxations, congenital, 323 
maerocephalus, 324 
macrodactylia, 324 
macroglossia, 324 
macrosomia, giants, 324 
microbrachius, 316 
microcephalus, 312 
micromelus, 316 
micropus, 316 
monopus, 316 
monstra duplicia, 324 

per defectum, 312 

per excessum, 324 

per fabricam alienam, 325 

triplicia, 325 
mylacephalus, 312 
obstructing labor, 445 
of heart, 318 

organs, absence of, 316-318 
perobrachius, 316 
peromelus, 316 
peropus, 316 
phocomelus, 316 
polydactylie, 325 
polymelia, 325 
prosopothoracopagus, 324 
pyopagus,324 
rachipagus, 325 
rachischisis, 321 
spina bifida, 321 
situs transversus, 325 
supernumerary extremities, 325 

organs, 325 
syncephalus, 324 
terata anacatadidyma, 324 

anadidyma, 324 

catadidyma, 324 
thoracopagus (Siamese twins), 324 



Foetus, anomalies of, uterus duplex, 320 
unicornis, 320 

asphyxia of, following version, 686 

attitude of, 191 

cerebral hemorrhages in, 328 

circumference of head of, 179 

conditions of, indicating forceps, 660 

dead, absorption from, 470 

a contraindication to use of forceps, 
659 

death of, 130, 329, 470 

an indication for induction of abor- 
tion, 642 
in placenta praevia, 501 

delivery of trunk of, 206 

descent of, in labor, 122, 201 

determination of position of, from ab- 
dominal palpation, 687 

diagnosis of death of, 329 

diseases of, 327 

effect of eclampsia upon, 518 

enlargement of head or body of, by dis- 
ease, 471 

errors in development of, etiology of, 
336 

extraction of, in Csesarean section, 720 

flexion of head of, in labor, 202 

heart-sounds of, 136, 138 

hemorrhage of, 328 

hereditary disease of, 327 

infectious diseases of, 328 

inflammation of, 328 

in uterine inertia, 404 

large size of, 470 

length of, in last months of pregnancy, 
152 

location of back and small parts of, 213 

malnutrition of, 329 

malposition of head of, obstructing 
labor, 445 

management of birth of trunk, 242 

mature, diameters of trunk of, 180 
length of, 180 
weight of, 180 

measurements of head of, 177 

mensuration of, in determining date of 
labor, 151 

method of expulsion of, 201 

mobility of head of, 180 

mortality of, in precipitate labor, 402 

moulding of, in breech presentations, 
456 

movements of, in ectopic gestation, 371 

mummification and calcification of, 375 

organic lesions of, 330 

papyraceus, 296 

pathology of, 312 

plane of head of, 179 

retaining position of, following external 
version, 682 

rotation of head of, in labor, 203 

size of, at different stages, 116 

treatment of anomalies of, obstructing 
labor, 475 

weight of, 470 

at different stages, 1 16 
Folding off of the embryo, 84 



48 



754 



INDEX. 



Fontanelles, 176 
at birth, 
closure of, 170 
raise, 177 

i as, in preeclamptic state, 

52 1 
Foramen magnum in craniotomy, 718 
of Munro, 99 
ovale, ( ->7, 266 

closing of, at birth, 98 
Forceps, application of, in high occipito- 
posterior cases, 448 

in occipito-posterior cases when 
head is low, 448 

to after-coming head, 076 

to breech, 675 

to occipitofrontal diameter, 702 
axis-traction, 676 

advantages of, 678 

Breus', 679 

Galabin's, 676 

Hubert's, 676 

indication for, 448, 675 

in obliquely contracted pelvis, 425 

Jewett's, 678 

Lusk's, 677 

operation with, 679 

Tarnier's, 677 
blades, removal of, 668 
Chamberlen, 655 
extraction with, high operation, 669 

low operation, 668 
in breech cases, 461 
in face presentation, 675 
in funnel-shaped pelvis, 418 
in justo-minor pelvis, 417 
in occipito-posterior positions, 673 
in uterine inertia, 406 
indications for, 451, 476, 484, 493, 507, 

696 
invention of, 655 
medium operation, 673 
obstetric, 655 

application of, 664 

Barnes', 657 

blades of, 656 

Braun's, 657 

cephalic curve of, 656 

compression with, 658 

contraindication to use of, 658 

direct traction with, 658 

Dubois', 657 

fenestration of, 656 

function of, 657 

handles of, 655 

Hodge's, 657 

indications for use of, 659 

Jewett's, 657 

lever action of, 658 

Levret's, 655 

lock of, 655 

material of, 656 

Naegele's, 657 

Pajot's, 657 

pelvic curve of, 656 

prerequisites to use of, 658 

rotative action of, 658 



Forceps, obstetric, -hank- of, 656 
short, Btraight, 656 
Simpson's, 667 
Wallace's, 657 

operation, 664 

amount Of tractile force in, 671 

cephalic application, 667 

dangers of, 661 

extraction in, 667 

genera] rules in, 672 

high, 664 

introduction offirsl blade, 665 

of second blade, 666 
line of pull in, (170 
locking, 666 
low, 66 1 
medium, 664 
posture of patient in, 663 
preparation for, 662 
steps of, 665 
traction in, 668 
Palfyn, 655 

paralysis caused by pressure of, 611 
pelvic application of, 665 
Poullet's, 676 

rupture of symphysis pubis from, 495 
Smellie's, 655 

with malacosteon pelvis, 428 
with version, 702 
Fossa, ischio-rectal, anatomy of, 36 

navicularis, anatomy of, 21 
Fourchette, anatomy of, 21 

rupture of, 631 
Fraenulum, anatomy of, 20 
Frontal protuberance, 177 
Fundus uteri, anatomy of, 46 

location of, by abdominal examina- 
tion, 134 
Funis, presentation of, 481 

reposition of, 483 
Furbringer method of sterilizing hands, 230 



GAIT, changes in. during pregnancy, 126 
Galactocele, 553 

treatment of, 554 
Galactorrhea, 553 
Gavage in infant feeding, 288 
Gelatin water in diluting milk, 279 
Genital fold, 112 

groove, 114 

labium, 114 

organs, foetal, lesions of, 333 

tubercle, 114 
Genitals, care of, during puerperium, 259 

cleansing of, for forceps operation, 662 

external, development of, 114 
during pregnancy, 124 
Germinal epithelium, 112 

spot, 76 

vesicle, 76 
Gill arches, 106 
Glands, Bartholin's, anatomy of, 44 

Skene's, anatomy of, 40 

thymus, development of, 106 

vulvo-vaginal, 45 
Glandulae vestibuli minores, 22 



INDEX. 



755 



Glans clitoridis, anatomy of, 24 
Glonoin in eclampsia, 532 
Glottis, development of, 109 
Gloves, operating, 231 
Glycosuria during pregnancy, 543 
Gonococcus in puerperal infection, 564 
Graafian follicle, anatomy of, 59 
development of, 74 



HEMATOCELE in ectopic gestation, 365 
Hematoma of broad ligament, 367 
of vulva, 496 
Haematometra, 136 

simulating pregnancy, 149 
Haemophilia, prenatal, 328 

post-partum hemorrhage caused by, 509 
Haines' method of computing urinary solids, 

211 
Hammock-bed, Ayres, 495, 743 
Hand, prolapse of, 465 
Hands, cleansing of, 230, 662 

disinfection of, 230, 595, 596 
Hart's law, 450 

Head, after-coming, rapid method of de- 
livery, 696 
-bend, primary, 98 
constriction of, by uterus in breech 

presentation, 460 
extraction of, in breech cases (Smellie 

method), 461 
forceps extraction of, in breech presen- 
tation, 461 
impaction of, in breech presentation, 

456, 461 
malrotation of, in breech presentation, 

463 
manual extraction of, in breech pre- 
sentation, 461 
-moulding, absence of, in ossified skull, 
470 
in brow presentation, 452 
in face presentation, 451 
in justo-minor pelvis, 417 
in occipito-posterior cases, 446 
Heads, foetal, detection of, in multiple preg- 
nancy, 298 
Heart, changes in, during pregnancy, 125 
development of, 91 

embryonic, size of, at first month, 117 
foetal, causes of inaudibility of, 138 
lesions of, 331 
location of, 217 
sounds of, 136 
infantile, congenital malformations of, 

608 
lesions of, in pregnancy, 544 
of new-born child, 266 
palpitation of, in hydramnios, 301 
physiological hypertrophy of, 544 
-sounds, foetal, 117 

feebleness of, 302 
in pelvic presentation, 454 
in transverse presentation, 465 
two in plural pregnancy, 298 
stimulants, use of, in cardiac disease 
complicating pregnancy, 546 



Heart, symptoms of valvular disease of, 545 
valvular disease of, complicating preg- 
nancy, 544 
Heat, dry, for antisepsis, 228 
moist, for antisepsis, 228 
Hegar's sign, 142 
Helix, development of, 105 
Hemicephalus, 472 
Hemiplegia, from forceps operation, 661 

in new-born infant, 612 
Hemispheres, cerebral, development of, 99 
Hemorrhage, accidental, 498 

diagnosis from placenta praevia, 

500, 506 
etiology and diagnosis of, 506 
prognosis and treatment of, 507 
varieties of, 505 
cerebral, in new-born infant, 612 
concealed (internal), 505 
following abortion, 341 
from circular artery, 640 
from uterine contractions, 194 
in abortion, 342 

in Caesarean section, control of, 726 
in ectopic gestation, 364 
in hydramnios, 302 
in placenta praevia, 499 
control of, 502 
in thrombosis of vulva, 496 
intracranial, at birth, 610 

from forceps operation, 661 
post partum, 508 

active treatment of, 511 
frequency and etiology of, 509 
in placenta praevia, 505 
in twin births, 476 
preventive treatment of, 510 
secondary treatment of, 515 
symptoms and prognosis of, 

510 
treatment of, 510 
with justo-major pelvis, 415 
with tumors of uterus, 441 
renal, in foetus, 333 
secondary post-partum, 508, 515 
source of, in placenta praevia, 498 
umbilical, in child, 618 
unavoidable, 498 

uterine, demanding use of forceps, 660 
following precipitate labor, 404 
in false labor, 394 
on death of foetus, 353 
Hemorrhagic diathesis, post-partum hemor- 
rhage from, 510 
Hemorrhoids in pregnancy, 393 
Hepatitis, interstitial, 620 
Heredity in puerperal insanity, 555 
Hernia, navel cord, 311 
of uterus, 439 

gravid, 722 
umbilical, in foetus, 475 
in new-born child, 619 
Hernia?, inguinal or crural, obstructing 

labor, 445 
Holoblastic segmentation of ovum, 78 
Hot-air bath, 525 
pack, 525 



756 



INDEX. 



1 [umerus, fracture of, at birth, 610 
Hydatids ftorgagni, 57, 1 L2 

Hydremia in eclampsia, 619 
Hydramni< i 

differential diagnosis of, 302 

etiology and symptoms of, 301 

frequency of, 301 

in multiple pregnancy, 297 

in plural births, 176 

post-partum hemorrhage from, 509 

prognosis and treatment of, 303 
1 [ydrencephalocele, 607 
Hydrocephalus, 171 

in fcetus, diagnosis of, 472 
relation of, to labor, 473 
treatment of, 473 
Hydrorueningocele, 471 
Hydronephrosis, fetal, 333, 474 
Hydrorrhacis, 475 
Hydrorrhcea gravidarum, 300 

diagnosis from hydramnios, 302 
Hydrothorax, foetal, obstructing labor, 474 
Hymen, anatomy of, 22 

tears of, 248 

various forms of, 23 
Hyoscin hydrobromate in puerperal insan- 
ity, 561 
Hyperemia, cerebral, in eclampsia, 519 
Hysterectomy, indication for, 488 

in puerperal infection, 603 
Hysteria, contraindication to nursing, 272 

diagnosis from eclampsia, 521 



ICE, in post-partum hemorrhage, 512 
Ichthyosis, foetal, 334 
Icterus neonatorum, 333, 619 
grave form, 620 
mild form, 619 
"true," 619 
Idiocy from forceps operation, 661 
Impregnation of ovum, site of, 77 
Incubation, period of, 294 
Incubators, 290 

temperature of, 292 
Inertia uteri, 403 

indication for forceps in, 660 
in twin births, 47b' 
retention of placenta from, 652 
Infant mortality with prolapsus funis, 482 
new-born, cyanosis of, 608 
overfeeding of, 287 
premature, care of, 290 

feeding of, 293 
stools of, 289 
weight-chart of, 289 
weight of, at birth, 288 
Infection, auto-, puerperal, 577 
intra-partum, 590 
maternal, from dead foetus, 329 
puerperal, 562 

from gas bacillus, report of a case, 
566 
Infectious diseases during pregnancy, 156 
Injections, intravenous, of salt solution, 508 
Insanity, puerperal, 555 
etiology of, 555 



[nsanity, puerperal, forms and symptoms 
of 556 

prodromal period of. 557 
prOgnOSlH and treatment of, 559 

Instruments tor repair of vaginal lacera- 
tions, Q3 l 

sterilization of. 228 
Insufflation, direct, in asphyxia. '11 1 

Intercourse, Bexual, during pregnancy, 154 

lnte-tinal fermentation in new-born child, 

626 
Intestine, development of, 108 
Intestines of new-born child, 268 
Intravenous injection of salt solution in 

post-partum hemorrhage, 513, 514 
[ntroitus ostium raginse, 22 
Inversion of uterus, complete, 485 
frequency, 484 
partial, \<) 

prognosis and treatment of, 487 
Involution, absence of* in endometriti 
in abortion, 343 
tardy, 262 
lodoform-gauze tampon of uterus, 513 
Iris, development of, 102 
Iron in pre-eclaraptic state, 525 

in puerperal insanity, 561 
Ischium, spine of, as an obstetric landmark, 
163 
tuberosities of, 1 63 
Islands of Pander, 90 

Isolation in treatment of puerperal insanity, 
560 



JAUNDICE, 620, 621 
Joints, pelvic, 160 

mobility of, 162 
sacro-coccygeal, 160 
sacro- iliac, 162 
suppuration of, 589 



KARYOKINESIS, 78 
Kidney, development of, 111 
Kidneys, diseases of, in puerperal eclampsia, 
518 
floating, obstructing labor, 445 
fcetal, lesions of, 333 
of new-born child, 268 
Kiestein, 126 
Knife of Farabeuf, 737 
of Galbiati, 737 
sickle-shaped, of Schultz, 716 



LABIA majora, anatomy of, 18 
development of, 115 
minora, anatomy of, 20 
development of, 115 
Labium, abscess of, 443 
Labor, abdominal examination in, 234 

accidental, complications of, indicating 

forceps, 660 
anaesthesia in, 238 

anomalies of, arising from accidents or 
disease, 481 



INDEX. 



757 



Labor, anomalies of, mechanism, 399 

cardiac disease an indication for indue 
tion of, 545 

causes of onset of, 193 

definition of, 192 

delayed, 402 

diagnostic signs of, 234 

duration of, 192 

effect of eclampsia upon, 518 

false or spurious, in ectopic gestation, 
374 

first stage, preparation of patient for, 
234 

general rules in management of, 236 

hemorrhages in, 498 

immature, treatment of, 350 

in bicornate uterus, 437 

in compressed pelvis, 428 

in kyphotic pelvis, 433 

in scoliotic pelvis, 436 

in twin births, 476 

induction of, in anaemia, 394 
in hydramnios, 303 
in pre-eclamptic state, 525 
Krause's method, 501 

management of, 211 
first stage in, 234 
in brow presentation, 453 
in face presentation, 451 
in multiple pregnancy, 298 
in occipito-posterior cases, 447 
in pelvic presentation, 456 
in placenta prsevia, 501 
in plural births, 476 
in second stage, 236 
in transverse presentation, 467 

mechanism of, 157 

in brow presentation, 452 

in face presentation, 450 

in flat rachitic pelvis, 421 

in obliquely contracted pelvis, 425 

in occipito-posterior position, 446 

in pelvic presentation, 455 

with large foetus, 470 

method of keeping history of, 226 

missed, 353 

normal, 192 

nurse's preparation for, 233 

pains of, 195, 200 

pathology of, 399 

perineal stage, management of, 240 

physiology of, 157, 399 

positions during, 236 

precipitate, 401 
causes of, 401 
post-partum hemorrhage following, 

509 
sequelae of, 402 
treatment of, 402 

prediction of date of, 151 

premature, 353 

definition of, 335, 641 
induction of, 641 

in obliquely contracted pelvis, 
425 
in multiple pregnancy, 298 
methods of inducing, 649 



Labor, premature, operation of induction 
of, 650 
treatment of, 354 
prematurity of, in plural births, 479 
preparation of bed for, 233 
of patient for, 232 
of room for, 232 
preparatory treatment for, 211 
probable date of, 150 
prognosis of duration of, 235 
prolonged, central paralysis from, 612 
record of, 225 
second stage of, 206 
spurious, changes after, 375 
stages of, 192 

third stage of, clinical phenomena of, 
209 
management of, 243 
vaginal examination during, 237 
walking about in the first stage, 235 
with contracted pelvis, 409 
with foetal monstrosity, 480 
with "funnel-shaped" pelvis, 418 
with justo-major pelvis, 415 
with justo-minor pelvis, 416 
with spondylolisthetic pelvis, 431 
Laceration of perineum, immediate suture 
of, to prevent infection, 598 
vaginal, immediate repair of, 629 

walls, 249 
vulvar, immediate repair of, 629 
Lactation, 255 

length of period of, 256 
termination of, 261 
Lactose in urine, 126 

during pregnancy, 543 
Lanugo, disappearance of, 118 
Larynx, development of, 109 
Laxatives for use in pregnancy, 155 
Lead-poisoning a cause of abortion, 336 
Lecithin in milk, 278 
Lemon juice in post-partum hemorrhage, 

512 
Levator ani, action of, 629 
Ligament, ano-coccygeal, 26 
broad, development of, 113 

(mesosalpinx), anatomy of, 53 
Cooper's, 68 

greater sacro-sciatic, 1 63 
interosseous, 160 
lesser sacro-sciatic, 163 
of bladder, 31 
of ovaries, anatomy of, 60 
pubic, 161 
round, of uterus, 60 
rigidity of, 136 
sacro-iliac, 160 
sacro-sciatic, relation to pelvic outlet, 

163 
triangular, 27 

anatomy of, 31 
uterine, anatomy of, 49, 60 
utero -sacral, 44 
Ligamentum arcuatum, 161 
Limbs, foetal, prolapse of, 469 
Linese albicantes, 134, 152, 255 
Liquor amnii, 201 



758 



INDEX. 



Liquor amnii, composition and function of, 

folliculi, 7 1 
Lithopedion, 375 
Liver, circulation of, in embryo, '. (|i 

development of, L08 

daring pr» gnancy, L26 

foetal, lesions of. 333 

<it' new-born child, 268 

tumors of, obstructing labor, 445 
Local conditions to be treated in puerperal 

insanity, 560 
Location of anterior sboulder, 216 

of cephalic prominence, 216 

of foetal back and small parts, 213 
heart, 217 
Lochia, 252 

alba, 252 

amount of, 252 

bacteriological examination of a series 
of cases, 568 

effect of stoppage of, 556 

in abortion, 343 

in puerperal infection, 587 

rubra, 252 

serosa, 252 
Lordosis deforming pelvis, 436 
Lubricants, 231 
Lungs, foetal, lesions of, 332 

of new-born child, 266 
Lying-in room, 232 
Lymphangitis, puerperal, 571 
Lymphatics, fetal, lesions of, 332 

of new-born child, 269 



MAGNESIUM sulphate to induce abor- 
tion, 644 
Malaria in pregnancy, 387 
Malarial fever simulating puerperal infec- 
tion, 591 
Malpighian bodies, development of, 111 
Malpositions in placenta prsevia, 501 
in twin births, 476 
with prolapsus funis, 481 
Malpresentations in placenta prsevia, 501 

with prolapsus funis, 481 
Malrotation of head in breech cases, 463 
Mammary glands, accessory glands of, 68 
anatomy of, 64 
changes of, in pregnancy, 66 
lobes of, 67 
lymphatics of, 71 
nerves of, 71 

signs of pregnancy in, 130 
vessels of, 69 
infection, source of, 551 
Management of labor, 234 
Massage in birth paralyses, 612 

mammary, 552 
Mastitis, 550 

etiology of, 550 

forms of, 551 

in new-born child, 618 

treatment of, 618 
prophylactic treatment of, 552 
symptoms of, 551 



Mastitis, treatment of, 552 

suppuration in, 552 

Masturbation, changes in breast from. 132 
Mauriceau method of extraction of bead in 
breech cases, 461 

.Maxilla, inferior, development of, 106 

fracture of, at birth, »>lu 
Maxillary process, L06 
McLean's bag, 503 
Meatus urinarius, anatomy of, 22 
Meconium, 289 

in diagnosis of breech cases, 464 
Medulla oblongata, development of, 100 
Medullary groove, 82 

plate, 82 
Melancholia, puerperal, .",.",7 
Membrana granulosa of Graafian follicle, 60 
Membrane, pseudo-diphtheritic, in puer- 
peral vaginitis, 570 
Membranes, adhesion of, 208 
caution in delivery of, 652 
conditions of, for application of forceps, 

659 
detachment of, 208 
early rupture of, 198 
examination of, 244 

in premature labor, 651 
in face presentations, 451 
in multiple pregnancy, 296 
premature rupture of, a cause of pro- 
lapsus funis, 481 
rupture of, 201, 237 

in accidental hemorrhage, 507 

in internal version, 690 

in partial detachment of placenta, 

502 i 
in uterine inertia, 405 
separation of, in induction of labor, 650 
uterine development of, 84 
Meningitis, diagnosis from eclampsia, 522 
Meningocele, 607 
Menses, suppression of, 148 
in pregnancy, 128 
Menstrual discharge, 73 
Menstruation, apparent, during pregnancy, 
129 
coincident with ovulation, 75 
disturbances of, in ectopic gestation, 364 
normal, 73 
physiology of, 73 
return of, after labor, 247 
Mental affections in pregnancy, 397 

condition, care of, during puerperium, 
259 
during pregnancy, 155 
impressions, a cause of onset of labor, 

195 
rest in puerperium, 258 
Mercurial ointment in congenital syphilis, 

624 
Mercuric chloride as an antiseptic, 229 

iodide as an antiseptic, 229 
Mesenchyme, 81 
Mesentery, development of, 108 
Mesoderm, development of, 80 
tissues developed from, 82 
Mesogastrium, 107 



INDEX. 



759 



Mesorectum, 37 
Mesothelium, 81 
Metastases in pyaemia, 589 
Metritis, chronic, 147 

puerperal, 574 
Metrorrhagia, a contraindication to nurs- 
ing, 272 
Milk, changes in, from sterilization, 283 
condensed, 284 
cow's, dilution of, 279 
modifying of, 278 
removal of casein from, 279 
effect of excess of fat in, 286 

of sugar in, 286 
"fever," 254, 590 
Gartner's, 282 
human and cow's, 276 

tabulated comparison of, 278 
variations in, 274 
hypersecretion of, 552 
laboratories, 285 
maternal, 272 

abnormal, 273 
composition of, 256 
presence of bacteria in, 551 
quantity of, 256 
method of modifying, 282 
microscopical examination of, 273 
Pasteurization of, 284 
peptonization of, 28] 
preparation of, Vigier's method, 281 
secretion of, in pregnancy, 132 
stasis, 550 
sterilized, 283 

advantages of, 284 
Miscarriage (immature labor), 335 
Mitral valve, lesions of, 544 
Mole, blood, 340 
fleshy, 340 
tubal, 363 
Mons pubis. See Mons veneris. 
Mons veneris, anatomy of, 17 
Monsters, double, obstructing labor, 480 

foetal, diagnosis of, 480 
Monstrosities in multiple pregnancy, 297 

obstructing labor, 479 
Monstrosity, embryotomy indicated, 708 
Montgomery's follicles, 132 
Morbus ceruleus, 98 
Mortality in eclampsia, 524 
in embryotomy, 719 
in version and symphysiotomy, 702 
maternal, in concealed "accidental 
hemorrhage," 506 
in placenta prsevia, 500 
in podalic version for placenta 

prsevia, 504 
in rupture of uterus, 493 
Mother, examination of, after labor, 245 
Moulding of foetal head, 207 

excessive, 609 
Mouth, development of, 105 
Muscles, abdominal, action of, in labor, 158 
coccygeus, 35 

compressor urethra?, anatomy of, 39 
constrictor vagina?, anatomy of, 27 
erector clitoridis, anatomy of, 27 



Muscles, Guthrie's, 39 

internal sphincter ani, anatomy of, 36 
levator ani, anatomy of, 32 
obturator internus, relation to parturient 
canal, 173 
anatomy of, 29 
pyriformis, relation to parturient canal, 
173 
anatomy of, 30 
sphincter ani, anatomy of, 26 

vagina?, anatomy of, 27 
transversus perinei, anatomy of, 27 
Muscular system, foetal, lesions of, 334 
Myomata, uterine, with prolapsus funis, 481 
Myotomes, development of, 83 



NAEGELE'S rule, 151 
Na?vi, 332 
Naphthalin internally, indication for, 561 
Nasal passages, development of, 107 
pits, 107 
process, 107 
Nausea during pregnancy, 129 
Navel, protrusion of, 133 
Neck-bend of embryonic brain, 98 
Nephritis, acute, an indication for induction 

of abortion, 642 
Nervous system, changes in, during preg- 
nancy, 127 
development of, 98 
diseases of, contraindication to 

nursing, 272 
disorders of, in pregnancy, 396 
of new-born child, 265 
Neural canal, 82 
Neuralgia in pregnancy, 396 
Nipple, anatomy of, 66 
erectility of, 132 
shield, 549 
Nipples, anomalies and diseases of, 547 
care of, 212 

during pregnancy, 154, 548 
fissures of, 261 

infection from, 550 
treatment of, 549 
irritation of, to stimulate uterine con- 
traction, 643 
sore, 547 

etiology of, 548 
treatment of, 548, 549 
Nitrate of silver in ophthalmia, 622 

for sore nipples, 550 
Nose, development of, 107 
Notochord, 83, 115 
Nourishment during puerperium, 257 
Nuclein in milk, 278 

in treatment of puerperal infection, 606 
Nucleolus of ovum, 75 
Nucleus of ovum, 76 
Nurse, antiseptic precautions for, 232 
Nursing-bottle, 287 
maternal, 271 

contraindications to, 272 
of infant, contraindications to, 260 

time of, 271 
painful, relief of, 549 



760 



INDEX. 



Nursing, to stimulate uterine contractions, 

w.t . 276 
Nutrition during pregnancy, 126 

vreighl as a sign of, 
Nymphs. S Labia minora. 



| VATMKAL water in diluting milk, 279 
\r Obesity resembling pregnancy, 147 
Obstetric Burgery, 629 

Obturator foramen, 168 

Occipital bone, resistance of, in crushing 
operation, 714 
protuberance, 177 
Occipito-posterior positions, 445 
abnormal, 440 
indications for symphysiotomy in, 

734 
right, 445 
Occiput, 177 

OEdenia during pregnancy, 125 
foetal, 333 

general, of foetus obstructing labor, 474 
in hydramnios, 301 
suprapubic, in plural pregnancy, 298 
OEsophagus, development of, 107 
Oidium albicans, 624 
Olfactory plates, 107 
Oligo-hydramnios, 300 

in plural births, 476 
Omentum, development of, 108 
Omphalo- mesenteric vessels, 93 
Oophoritis, puerperal, 574 
Operating gown, 062 

suit, 231 
Operation for immediate repair of internal 
vaginal lacerations, 633 
of lacerated cervix, 640 
Ophthalmia neonatorum, 621 

treatment of, 622 
Opisthotonos in eclampsia, 517 
Opium in abortion, 346 

in "accidental hemorrhage," 507 
in eclampsia, 527 
in uterine inertia, 405 
Optic cup, primary, 101 
secondary, 102 
nerves, development of, 99 
vesicles, development of, 99 
Oral plate, 105 

Organs, abdominal, enlargement of, re- 
sembling pregnancy, 148 
of Rosenmiiller. See Parovarium, 
of special sense, development of, 101 
Osseous system, changes in, during preg- 
nancy, 126 
foetal, lesions of, 333 
Osteophytes, puerperal, 126 
Otocyst. See Auditory vesicle, 104 
Outlet, pelvic, diameters of, 168 
landmarks of, 163 
plane of, 165 
Ovarian cystoma, diagnosis from hydram- 
nios, 302 
Ovaries, anatomy of 57 
nerves of, 64 



< Ovaries, vessels of, 64 

( )\:irv, cortical /one of, 59 

development of, 1 1 2 

tumors of, obstructing labor, 144 
tunica albugines of, 59 

zona VaSCUlosS of, 59 

Oviducts. See Fallopian tubes. 

( )vula of Naboth, 49 

Ovulation, physiology of, 74 

Ovum, changes in, in ectopic gestation, 360 

development of, 75 

fertilization of, 75, 77 

loosening attachment of, in labor, 194 

maturation of, 75 

nourishment of, 85 
Oxygen in eclampsia, 53 1 

inhalations in preeclamptic state, 525 
Ozaenaa source of infection in puerperium, 
576 



PAD, perineal, 633 
Pain in ectopic gestation, 374 
Pains, after-, 209, 252, 259 
in uterine inertia, 403 

rupture, 491 
labor-, 200 

weakness of, 402 
Pallor in insanity, 558 

Palpation of foetal parts in abdominal ex- 
amination, 134 
of lower foetal pole, 214 
of upper foetal pole, 215 
Palpitation during pregnancy, 125, 393 

from heart lesions, 545 
Pancreas, development of, 109 
Paralysis, central, in new-born child, 612 
Duchenne's, diagnosis of, 612 

in new-born child, 611 
Erb's, 611, 612 
facial, in new-born child, 610 
Parametritis, puerperal, 573 
Parietal bone, craniotomy with removal of, 
711 
protuberance, 177 
Parovarium, 113 
anatomy of, 60 
development of, 52 
Pars intermedial is, 29 
Parsley, ecbolic action of, 643 
Passages, maternal, obstructions of, indicat- 
ing use of forceps, 660 
Pathology of foetus, 312 

of pregnancy, 295 
Patient, disinfection of, preparatory to 

labor, 595 
Pelvic deformities, classification of, 414 

floor, action of, in labor, 159, 173, 203 
anatomy of, 26-28 
blood and nerve supply of, 61 
changes in, during pregnancy, 124 
fascia? of, 629 
measurements of, 173 
muscles of, 26-28 
retraction of, in labor, 200 
segments of, 173 
organs, care of, during pregnancy, 154 



INDEX. 



761 



Pelvic organs, female, anatomy of, 17-64 
presentation, 453 

management of special conditions 
in, 457 
Pelvimeter, 220 
Hirst's, 224 
Pelvimetry, 411 
external, 220 
internal, 222 
Pelvis, anchylosis of joints of, 433 
antero-posterior diameters of, 411 
articulations of, during pregnancy, 124 
bony, development of, 115 
cavity of, 172 

comparison of male and female, 171 
compressed (malacosteon), 427 
treatment of labor in, 428 
constituent parts of, 160 
contracted, forceps in, 660 

obliquely (Naegele pelvis), 424 
etiology and diagnosis of, 425 
from imperfect use of one 

limb, 426 
from lateral curvature of spine, 
426 
symphysiotomy in, 734 
transversely (Robert pelvis), 426 
from kyphosis of spine, 427 
version in, 703 
deep, 418 
deformities of, 409 
diagnosis of, 410 
frequency of, 410 
from osteomalacia, 411 
from rachitis, 410 
from spinal curvature, 433 
from tuberculosis, 411 
diameter of, diagonal conjugate, 413 
transverse, 167, 412 
true conjugate, 167 
distorted bv inj uries, disease, or tumors, 

431 
dwarf, 415 
dynamic, 168 

examination of, in pregnancy, 140 
external circumference of, 170 
diameters of, 169, 412 
measurements of, 169, 411 
false, 162 
flat, rachitic, 419 

etiology of, 420 
treatment of, 704 
simple, 418 

symphysiotomy in, 704, 734 
version in, 703 
fractures of, 433 
funnel-shaped, 418 
Hirst's measurement of, 413 
inclination of, 166 
infantile, 415 
internal diameters of, 167 

measurements of, 168, 413 
justo-minor, etiology of, 416 

treatment of labor in, 417 
kyphoscoliotic, 436 
kyphotic, 433 

diagnosis of, 434 



Pelvis, Lohlein's measurement of, 413 
masculine, 417 
measurements of, 170 
methods of immobilizing, 743 
muscles of, 173 
oblique diameters of, 412 
obstetric anatomy of, 159 

planes of, 164 
outlet of, 162 
pseudo malacosteon, 421 

-rachitic, 428 
rachitic, generally contracted, 421 
infantile, 421 
treatment of labor in, 423 
racial differences in, 172 
scoliotic, 435 
shallow, 417 

small, in puerperal eclampsia, 521 
soft parts of, 172 
split, 433 
spondylolisthetic, 429 

etiology and diagnosis of, 430 
true, 162 

cavity of, 163 
margin of, 162 
uniformly contracted, justo-minor, 415 
enlarged, justo-major, 415 
Penis, development of, 115 
Pennyroyal, ecbolic action of, 643 
Perchloride of iron in post-partum hemor- 
rhage, 512 
Perforation, indications for, 480, 659 
Perforator, Blot's, 711 
Pericardial effusion, foetal, 474 
Perineal body, 35 

ledge, anatomy of, 28 

space, anatomy of, 17 

Perineum, anatomy of, 18, 35 

effect of extensive rupture of, 556 
lacerations of. See Vaginal lacerations, 
in precipitate labor, 402 
in rapid delivery, 697 
prevention of, 240 
Peritoneum covering the ovary, 59 

pelvic, 123 
Peritonitis, 588 

in ectopic gestation, 374 
puerperal, 574 
Perivitelline space, 76 
Peroxide of hydrogen as an antiseptic, 229 
Phantom tumor, 149 
Pharynx, development of, 106 
Phlebitis, puerperal, 571 
Phlegmasia alba dolens, 575 

in puerperal infection, 589 
Physiology of ovulation, 74 
Physometra, 353 
Pica. See Malacia. 
Pigmentation in pregnancy, 126 
of abdomen in pregnancy, 134 
of breasts, 130 

of nipples and abdomen, 255 
Pilocarpine in eclampsia, 532 
Pinard's rule, 470 
Placenta, adherent, 308, 651 
causes of, 652 
treatment of, 652 



762 



INDEX. 



Placenta, anomalies <■' 
battledore, 306, 310 _ 
calcareous degeneration <>t". 308 
causes of retention <>t', 862 
changes In, in ectopic gestation, 863 
complete separation of, in placents prav 

\i:i. 

cotyledons of, v ^ 

( rede's method of expulsion of, 244, 

652 
detachment of, in placenta provia, 506 
diseases of, 308 
duplex, .SOT 
examination of, 244 

in premature labor, 651 
expression of, 243 
expulsion of, in twin birth, 298 
fatty degeneration of, 308 
horseshoe shape, 499 
in gradual delivery following version, 

698 
in multiple pregnancy, 296 
location of, 220 

from external signs, 136 
membranacea, 306 
method of expulsion of, 208, 598 
partial separation of, in placenta pre- 
via, 505 
position of, 306 
praevia, 498 

combined version in, 682 

diagnosis and prognosis of, 220, 
500 

etiology and symptoms of, 499 

examination of, by vagina, 500 

frequency of, 498 

post-partum hemorrhage from, 510 

structural anomalies of, 499 

treatment of, 501 

after the foetus is viable, 501 
before the seventh month, 501 

varieties of, 498 
retained, 651 

secondary hemorrhage from, 515 

treatment of, 652 
shape of, 306 
size of, 306 
structure of, 88 
syphilis of, 310 

treatment of, in Caesarean section, 725, 
726 

in rupture of uterus, 494 
tubercle bacilli in, 309 
tumors of, 309 
white infarctions of, 308 
Placentae in triplet births, 479 
spuria?, 308 

succenturiatae, 296, 307 
Placental apoplexy, 308 

symptoms and treatment of, 309 
separation, mechanism of, 651 
Placentitis, 308 

adherent placenta from, 652 
Plane of pelvic brim, 165 

outlet, loo 
pelvic, middle, 165 

diameters of, 168 



Pleural bbcs, development of, 109 
Plexus, inferior hypogastric, 64 
pampiniform, 6 I 

pelvic, I 

Plica transversalis recti, 37 
Pneumococcus in puerperal infection, 566 
Pneumonia, foetal, 332 
Polar globule, 77 
Polyhydramnios, 301 

Polypi, decidual, 3 W 

uterine, secondary hemorrhage from, 
516 
Polvpus of uterus, diagnosis from inversion. 

487 
Pons Varolii, development of, 99 
Porro- Csesarean section, indications for, 729 
technique of operation, 730 
operation, 729 

advantages of, 729 
for carcinoma of cervix with preg- 
nancy, 442 
in malacosteon pelvis, 428 
Position, determination of, from foetal heart- 
sounds, 139 
diagnosis of, 213 
dorso-posterior, version in, 701 
mento-anterior, indication for forceps 

in, 660 
occipito-posterior, indication for forceps 

in, 660 
of presenting part, 181, 182 

determination of, 235 
Posterior commissure, 18 
Posture of foetus, 191 

of patient in forceps operation, 663 
Praeputium, anatomy of, 20 
Prague method of extraction of head in 

breech cases, 461 
Pregnancy, abdominal, 355 
signs of, 133 
without rupture, 369 
affected by justo-major pelvis, 415 
changes in maternal organs caused by, 

119 
cornual, 355, 385 
diagnosis of, 128 

general rules for, 147 
diseases of, 387 
duration of, 150 
early abortion in, 336 
extra-uterine. See Ectopic gestation, 
general changes during, 124 
hygiene of, 153 
infundibular, 355 
in patients not menstruating, 129 
interstitial, 355 
management of, 153 
multiple, 295 

diagnosis of, 297 
frequency of, 295 
mode of origin of, 295 
pathology of, 297 
post-partum hemorrhage from, 509 
ovarian, 355 
pathology of, 295 
pelvic signs of, 140 
physiology of, 73 



INDEX. 



763 



Pregnancy, plural, heart-sounds in, 139 
post-mortem evidences of recent, 152 
previous, evidence of, 152 
recent, signs of, 263 
signs of, tabulated by months, 146 
tubal, 355 

rupture of, diagnosis from acci- 
dental hemorrhage, 507 
unruptured, 369 
twin, diagnosis from hydramnios, 302 
value of mammary signs in, 132 
Premature infants, care of, 290 
Preparations for labor, 232 
Presentation, breech, prolapse of limbs in, 
469 
brow, 452 

determination of, from foetal heart- 
sounds, 139 
diagnosis of, 213 
face, diagnosis and prognosis of, 449 

etiology of, 448 
head, prolapse of limbs in, 469 
longitudinal, 181 

pelvic, abnormalities in mechanism of, 
456 
diagnosis of, 454 
frequency of, 453 

management of special conditions 
in, 457 
transverse, 181, 463 
diagnosis of, 464 
positions in, 464 
prolapse of limbs in, 469 
spontaneous delivery in, 465 
varieties of, 463 
vertex, recognition of, 235 
Presentations in twin births, 476 

relative frequency of different, 181 
Presenting part, 181 
Primipara, eclampsia in, 521 
Primitive streak, 82 
Processus globulari, 107 
Prolapsus funis, diagnosis and prognosis of, 
482 
frequency and etiology of, 481 
indication for use of forceps in, 660 
treatment of, 483 
uteri, 440 
Pronucleus, female, 77 

male, 78 
Protargol in ophthalmia, 622 
Protuberances of foetal skull, 177 
Psychical disorders from forceps operation, 

661 
Ptyalism in pregnancy, 392 
Pudendum, vessels and nerves of, 21 
Puerperal auto -infection, 577 
fever, epidemics of, 575 
infection, 562 

air a source of, 577 
bacteriology of, 563 
curative treatment of, 599 
diagnosis of, 590 
etiology of, 575 
external modes of, 576 
frequency of, 584 
organisms causing, 562 



Puerperal infection, pathology of, 569 
symptomatology of, 586 
treatment of, 595 

state, definition of, 247 

sweats, 255 

woman, care of, 257 
Puerperium, danger of infection in, 248 

diagnosis of, 263 

pathology of, 547 

physiology of, 247 
Pulmonary congestion in pregnancy from 
cardiac disease, 545 

organs, development of, 109 
Pulse after labor, 254 

chart, 226 

foetal, during labor, 201 

in acute anaemia, 500 

maternal, in labor, 201 

with post-partum hemorrhage, 510 
Purgation to induce abortion, 644 
Putrefaction, intestinal, absorption of pro- 
ducts of, as a cause of puerperal in- 
sanity, 556 

of foetus without sepsis, case of, 718 
Pyaemia, 589 

puerperal, 574 
Pyosalpinx, 588 
Pyrosis in pregnancy, 387 



QUICKENING, 130 
appearance of, 117 
reckoning date of labor from, 151 
Quinine, ecbolic action of, 643 
in uterine inertia, 405 



T)ECESSUS labyrinthi, 104 
it Kecord, obstetric case-, 224 
Eectal injections of salt solution, 513 
Eectum, anatomy of, 36 

carcinoma of, secondary hemorrhage 

from, 516 
congenital malformations of, 609 
distention of, obstructing labor, 443 
impacted, a cause of retained placenta, 

652 
relation of, to parturient canal, 173 
structure of, 36 
Eespiration, artificial, in asphyxia of new- 
born child, 615 
Byrd's method, 615 
Laborde's method, 617 
Schultze's method, 615 
changes in, during pregnancy, 125 
disorders of, in pregnancy, 394 
following labor, 255 
in early infancy, 266 
of new-born child, 269 
Eestitution of foetal head, 206 
Eetina, development of, 102 
Eetraction of uterus, 244 
Eetroflexion of uterus resembling pregnancy, 

147 
Eheumatism, chronic, contraindication to 

nursing, 272 
Eings, cervical, 199 



764 



INDEX. 



Kinu r of Band], I 97 

Ho , lvii 

Rotation, complete, io transverse presenta- 
tion, loo 

external, of foetal bead, 206 

of bead in labor, 203 
Hue. acholic action of, ,; L3 
Rupture of uterus, 488 



OA( ' HAROMYCES albicans, 624 
U Sacculus, develo| men! of, 104 
Sacrum, promontory of, 1 62 

Salivation during pregnancy, 130 
Salpingitis, -~>>s 
puerperal, 574 

Salt solution, ol3 

injection of, in treatment of puer- 
peral infection, 606 
use of, in eclampsia, 532 
Saprsemia from dead foetus, 719 

puerperal, 567 
Savine, ecbolic action of, 643 
SchmoiTs theory of eclampsia, 519, 520 
Schneiderian membrane, development of, 

107 
Scissors for decapitation, 716 

Smellie's, 710 
Sea voyages, effect of, on menstruation, 129 
Secretion, vaginal, in labor, 201 
Secundines, retained, post-partum hemor- 
rhage from, 509 
Semicircular canals, development of, 104 
Seminiferous tubules, 112 
Senses, special, of new-born child, 266 
Sepsis, foudroyante, 569 
in abortion, 344 

treatment of, 349 
in ectopic gestation, 375 
in new-born child from umbilical in- 
fection, 621 
puerperal, treatment of, 599 
Septic infection a cause of puerperal in- 
sanity, 556 
Septicaemia, 589 

Septum inferior in embryonic circulation, 93 
recto-vaginal, 43 

superior in embryonic circulation, 92 
urethro-vaginal, 39, 44 
vesico-vaginal, 43 
Serum, anti-streptococcus, in puerperal in- 
fection, 603 
Sewer-gas, infection from, 577 
Sex of foetus, determination of, by heart- 
sounds, 136 
Sexual gland, 112 

organs, development of, 51 
Shoulder, anterior, location of, 216 
delivery of, in normal labor, 206 
presentation of, 466, 719 
Silkworm-gut suture in vaginal repairs, 634 
Sinciput, 177 

" Sinus terminalis " in embryonic circula- 
tion, 90 
uro-genital, 51 
venosus, 93, 96 
Situs transversus, 332 



Skeleton, development of, l L5 

Skin, changes in, during pregnancy, L26 

foetal, lesions of, 33 1 

following labor, 255 

of Dew-born child, 269 
Skull, foetal, unduly ossified, 470 
Sleep in pregnancy, 153 
Solution-, antiseptic, 229 
Somatopleure, development of, 84 
Souffle, funic, L39 

placental, in ectO| ic gestation after 

fourth month, 372 
uterine, L39 
Spermatozoon, fertilization of ovum by, 78 
Sphincter ani. repair of rupture of, 637 
retraction of torn ends of, 637 
rupture of, 636 
raginse, 22 
vesica-. 37 
Spina bifida, 607 

accompanying hydrocephalus, 472 
treatment of, 608 
Spinal canal at first month, 116 

column of new-born child, 265 
cord, columns of, 100 
development of, 100 
fissures of, 100 
injuries to, at birth, 610 
Splanchnopleure, development of, 84 
Spleen during pregnanes , 126 

foetal, lesions of, 332 
Spondylolysis in transverse presentation, 469 
Spondylotomy in transverse presentation, 469 
" Spontaneous evolution," 707 
rare variety of, 466 
rupture of uterus, 491 
version, 465 
Sprue. See Thrush. 

Staphylococcus in puerperal infection, 564 
Steam sterilization, 228 
Stenosis, anal and rectal, 609 
Sterility, diabetes a cause of, 543 
Sterilizer, Arnold, 228 
Sterno-cleido- mastoid, hematoma of, at 

birth, 610 
Stethoscope in abdominal examination, 138 
Stimulants in post-partum hemorrhage, 512 
Stomach, development of, 107 
infantile, capacity of, 287 
of new-born child, 267 
Strait, inferior, 162 

superior, 162 
Streptococcus erysipelatis, 577 

in puerperal infection, 563 
Strychnine in puerperal infection, 602 
Stump, uterine, extraperitoneal treatment 

of, 730 
Subcutaneous injections of salt solution, 514 
Submammary bursa?, 67 
Sugar, comparison of, in human and cow's 
milk, 277 
in milk, effect of sterilization upon, 283 
in urine following labor, 253 
Sulphonal in puerperal insanity, 561 
Superfecundation, 297 
Superfoetation, 297 
Supernumerary nipples, 547 



INDEX. 



765 



Suprapubic pressure on uterus in breech 

cases, 457 
Suprarenal capsule, development of, 111 
Suture of uterus in Cesarean section, 727 

silk, use of, 637 
Sutures, buried catgut, use of, 637 
of foetal head, 175 

coronal, 175 
lambdoidal, 175 
sagittal, 175 
Symphysiotomy, a substitute for embryot- 
omy, 733 
closure of wound in, 742 
contraindication to, 734 
defined, 730 
history of, 730 
indication for, 453, 470, 733 
in flat pelvis, 424 
in "funnel-shaped" pelvis, 318 
in tumors of pelvis, 432 
methods of rest following, 742 
mortality of, 705, 732 
objections to, 733 
or version, 704 

present status of the operation, 733 
rationale of the operation, 735 
technique of the operation, 735 
with version, 702 
Symphysis pubis, 162 

rupture of, 494 

causes, diagnosis, prognosis, 
and treatment of, 495 
Synclitism, 203 
Syncope, 500 

in pregnancy, 393 
Syphilis, adherent placenta from, 652 
congenital, a cause of icterus, 620 
Colles's law, 623 
treatment of, 624 
foetal, 338 
in new-born child, 623 



TACHYCARDIA, foetal, 331 
Talipes, centric, 333 
Tampon, cervical, in " accidental hemor- 
rhage," 507 
in placenta prsevia, 503 
iodoform-gauze, indication for, 721 
vaginal, for induction of premature 
labor, 650 
in accidental hemorrhage, 507 
in placenta praevia, 502 
to induce abortion, 645 
Tansy, ecbolic action of, 643 
Tarnier's bag, 503 

Taxis in repositing inverted uterus, 488 
Temperature after labor, 253 

causes of rises of, in puerperium, 590 
•chart, 226 
Temporal fontanelle, 176 
Tents for dilatation of cervical canal, 650 
Testis, development of, 112 
time of descent of, 118 
Tetanus neonatorum, 622 
treatment of, 622 
uteri, 406 



Tetanus uteri, diagnosis, prognosis, and 
treatment of, 407 
in version, 693 
Thorax of new-born child, 266 
Thrombosis following abortion, 648 
of vagina and vulva, 495 

etiology and symptoms of, 496 
treatment of, 497 
Thrush, 624 

symptoms and treatment of, 625 
Thyroid gland during pregnancy, 125 
Tongue, development of, 107 
Tonsils, development of, 106 
Torticollis in breech delivery, 455 
Toxaemia, theory of, in puerperal eclampsia, 

519 
Trachea, development of, 109 
Tragus, development of, 105 
Transfusion in post-partum hemorrhage, 513 
Transverse presentation, 463, 465 

dorso-anterior position, 464 
impacted, 714 
Traumatism, detachment of placenta from, 

506 
Trendelenburg posture in reposition of 

cord, 4fe3 
Trephine, obstetric, 712 

Martin's, 711 
Triplets, 479 
Truncus arteriosus, 93 

Tube, Fallopian, changes in ectopic gesta- 
tion, 360 
conditions of, causing ectopic ges- 
tation, 359 
hemorrhages in, in ectopic gesta- 
tion, 362 
low insertion of, a cause of pla- 
centa prsevia, 499 
Tuberculosis, foetal, 332 
in new-born child, 623 
maternal, contraindication to nursing, 

272 
paternal, a cause of abortion, 336 
Tubuli lactiferi, 69 
Tumors affecting pelvis, 431 

foetal, obstructing labor, 475 
ovarian, obstructing labor, 444 
Twins, 476 

head and breech presenting, treatment 

of, 478 
interlocking, 477 
pregnancy, dyspnoea from, 125 
with prolapsus funis, 481 
sex of, 296 
Tympanites, differential diagnosis from 
pregnancy, 147 
in peritonitis, 589 
Typhoid fever simulating puerperal infec- 
tion, 592 



ULCERS, puerperal, 569, 588 
treatment of, 599 
Umbilical cord, formation of, 88 
Umbilicus, infection of, in new-born child, 
620 
vegetations of, in child, 618 



766 



INDEX. 



Urachus, de\ elopment of, 1 1 1 
Urea, estimation of, during pregnancy, 155 
excretion of, in pregnancy, 628 
importance of testing for, 21 1 
test for, Bartley's, 212 
Ureters, course of, 63 

development of, 1 1 1 
Urethra, anatomy of, •">'.' 
development of. 1 15 
Urinary solids, 21 i 
Urine, changes in, after labor, 253 
conditions of, in eclampsia, 519 
during pregnancy, 156 
examination of, 21 1 

before operation, 724 
in pregnancy, 523 
of new-born child, 269 
retention of, from pressure on ureters, 

521 
suppression of, in puerperal eclampsia, 
521 
Urogenital sinus, 113 

system, development of, 109 
Ustilago maid is, 643 

Uterine adnexa during pregnancy, 123, 251 
contractions affected by hemorrhage, 
506 
causes of, 193 
effect of, on placenta, 651 
excessive, treatment of, 493 
hour-glass, 653 
intermittent, 195 
involuntary, 195 
methods of promoting, 643 
peristaltic character of, 195 
stimulation of, 511 
discharge, examination of, in ectopic 

gestation, 373 
incision in Cesarean section, closure of, 

726 
mucosa during puerperium, 251 
Utero-vaginal canal, development of, 113 
Uterus, action of segments of, in labor, 197 
anatomy of, 45 
anteflexion of, resembling pregnancy, 

144 
as a part of parturient canal, 172 
atony of, 303 

bulging of body of, in pregnancy, 142 
carcinoma of, during pregnancy, 706 
changes in, during menstruation, 73 
pregnancy, 119 
ectopic gestation, 359 
following fecundation of ovum, 87 

labor, 249 < 
from child-bearing, 47 
properties of, during pregnancy, 

122 
shape and size in contraction, 158 
compressibility of lower segment of, 

143 
consistence of, in pregnancy, 142 
contraction of, following Cesarean sec 
tion, 726 
in labor, 195 
date of appearance of signs of preg- 
nancy, 144 



Uterus, dilatation of, in foetus, 17 1 

displacement or, a cause of abortion, 

daring puerperium, 263 

distention of. a cause of onset of labor, 

195 
early changes of, in pregnancy, 141 
emphysema of, 470 

examination of, alter Caesarean section, 
729 
in puerperal infection, 599 

fallacies in examination of, 1 1 1 

fixation of, a cause of abortion 
complicating version, 701 

growtbs of, B cause of rupture, 490 
hyperemia of, resembling pregnancy, 

144 
indication for removal of, 729 
inertia of, 403 

causes of, 403 

diagnosis and prognosis of, 404 

in post-partum hemorrhage, 509 

symptoms, 403 

treatment of, 405 
injuries to, in forceps operation, 661 
inversion of, 484 

secondary hemorrhage from, 516 

symptoms and diagnosis of, 486 

treatment of, 487 

varieties and etiology of, 485 
inverted, reposition cf, 487 
involution of, 250 

in ectopic gestation, 359 
isthmus of, 45 
laceration of lower segment of, in rapid 

delivery, 528 
latero-version of, 440 
longitudinal fibres of, 198 
lower segment of, after labor, 210 

in transverse presentation, 465 
lymph spaces of, 63 
malpositions of, 439 
masculinus, 112 
mensuration of, in determining date of 

labor, 151 
method of making cultures from, 592 

of removal in Porro operation, 730 
micro-organisms of, 579 
motor centres of, 157, 193 
muscle cells of, 250 
muscular structure of, 47 

tissue of, 250 
nerves of, 64 
new growths of, 440 
normal measurements of, 46 
perforation of, in curettage, 352 
peritoneal covering of, 210 
position of, 53 

during pregnancy, 121 
prolapse of, following symphysiotomy, 

731 
retraction of, 209, 244 

in labor, 196 
retroflexion of, an indication for induc- 
tion of abortion, 642 
retroversion of, in abortion, 345 

resembling pregnancy, 144 



INDEX. 



767 



Uterus, rupture of, 488 

before second stage of labor, 490 

complete, 489 

danger of, in placenta prsevia, 540 
in version, 699 

etiology of, 490 

exciting causes of, 491 

frequency of, 489 

incomplete, 490 

indications for forceps in, 660 

in hydrocephalus of foetus, 473 

in rapid delivery, 530 

in spasmodic contraction, 407 

in transverse presentation, 465 

in version, 699 

pathology of, 489 

predisposing causes of, 490 

premonitory signs of, 491 

prognosis of, 492 

recovery in, 700 

spontaneous, 489 

symptoms of, 481 

traumatic, 489, 490 

treatment of, 493 
sacculation of, 440 
segments of, 172, 195 

action of, causing rupture, 491 

in rupture, 489 
shape of, 119 

in transverse presentation, 464 
situation of, after labor, 210 
size of, 119 

in pregnancy, 144 
sound measurements of, during puer- 

perium, 250 
spasmodic contraction of, 406 
strength of contractions of, 159 
structure of, 120 
subinvolution of, resembling pregnancy, 

144 
table of comparative measurements of 

multiparous and parous, 249 
vaginal fixation of, complicating de- 
livery, 701 
ventro-fixation of, complicating de- 
livery, 701 
vessels of, 62 

and nerves of, changes during 
labor, 251 
Utriculus, 104 



VAGINA, after-treatment in operation for 
deep tears of, 639 
anatomy of, 40 
bulbs of, anatomy of, 28 
changes in, during pregnancy, 123 
cysts of, obstructing labor, 443 
deep tear of, method of operating, 636 
development of, 113 
during puerperium, 249 
fornices of, 41 

injuries to, in forceps operation, 661 
lacerations of walls of, 249 
length of, 42 
lymphatics of, 62 
micro-organisms of, 581 



Vagina, purplish hue of, in pregnancy, 141 
shortening of, resembling prolapsus 

uteri, 44 
stenosis of, 442 
structure of walls of, 42 
swellings of, obstructing labor, 442 
thrombosis of, 495 
tumors of, obstructing labor, 443 
vessels and nerves of, 62 
Vaginal examination in placenta prsevia, 
500 
in rupture of uterus, 492 
in transverse presentation, 465 
lacerations, combined external and in- 
ternal, 632 
complete tear, 636 
internal, immediate repair of, 

method of operating, 633 
repair of, after-treatment, 635 
superficial external, repair of, 631 
outlet, injury to, in labor, 630 

superficial external tear of, 631 
secretion, 580 

errors in obtaining cultures of, 583 
microscopical examination of, 580 
normal and pathological, 582 
reaction of, 582 
signs in multiple pregnancy, 298 
Vaginitis, puerperal, 570 
Valves of Houston, 37 
Varices in pregnancy, 393 
Varolian bend of embryonic brain, 98 
Vasculitis, foetal, 331 
Vas deferens, development of, 112 
Vein, azygos, development of, 96 
iliac, development of, 96 
portal, development of, 96 
pulmonary, development of, 97 
Veins of embryo, 95 
Vena cava superior, development of, 96 
Venesection in pregnancy, 124 
Ventricle, fourth, development of, 100 
Veratrum viride in eclampsia, 532, 540 
Vermiform appendix, 108 
Version, 680 

and forceps, 702 

and symphysiotomy, 702 

in transverse presentation, report of 
a case, 702 
artificial, in transverse presentations, 

467 
bipolar, Braxton Hicks's method, 467 

method in placenta pnevia, 504 
cephalic, complications of, 701 
combined, 682 

advantages of, 684 
indication for, 682 
technique of, 683 
complications of, 699 
conditions necessary for, 680 
externa], 680 

indications for, 681 
technique of, 681 
frequency of, 705 

limitations of, 680 
in contracted pelvis, 703' 
in obliquely contracted pelvis, 425 



768 



INDEX. 



Version in rapture of uterus, i 
indication for, i ;, i . 473, 18 l 
Internal, 68 i 

choice of foot, 691 

of band in, ,|Vs; 
indical ions for, 68 I 
line of traction in, •'-'.•L > 
method of operating, r > v: > 
podalic, indication for, 468 
posture of patient in, 686 
preliminaries of, ( '> s 7 
mortality in. 705 
partial, 68 I 

podalic. in placenta pravia, 504 
precautions of, 'i'. 1 -'' 
results of, 705 

unusual complications in, 700 
uterine rupture from, 491 
with abnormal fixation of uterus, 701 
with carcinoma of uterus, 706 
with pelvic deformity, reports of cases, 
699 
Vertebne, injuries to, at birth, 610 
Vertex, foetal, 177 
Vesicle of Purkinje, 76 
Vesico-uterine pouch, 39 

-vaginal fistula, following symphysi- 
otomy, 731 
Vesicular mole, 304 
Vestibule, anatomy of, 21 
Viburnum prunifolium in abortion, 346 
Vinegar in post-partum hemorrhage, 512 
Visceral arches at first month, 116 
Vitelline membrane, 76 

veins, 93 
Vitellus of ovum, 76 
Vitreous humor, development of, 102 
Vomiting in labor, 200 

of pregnancy, 129, 388 



Vomiting of pregnancy, causes of, 388 

diaL r ii"-i- Of, 

Induction of abortion in, 642 
pernicious, 389 

diagnosis and treatment of, 
390 
Btages of, 389 

BUrgical methods in treatment of, 

391 
symptoms of. 
Vulva conn ivens, 18 

hsematoma of, 1 12 

hians, L8 

oedema of, obstructing labor, 443 

stenosis of, II- 

thrombosia of, 495 

tumors of, obstructing labor, 443 

varicose veins of, 443 
Vulvar dressing, 246 



WALCHER'S position, 237, 663 
indication for, 695 
Weight during pregnancy, 126 

loss of, in puerperium, 255 
Wharton's jelly, 89 
"White line," anatomy of, 30 
Widal's test of typhoid fever, 592 
Wigand-Martin method of extraction of 

head in breech cases, 461 
Wiring after rupture of symphysis pubis, 

495 
Wolffian bodies, 109 

anatomy of, 51 
Wormian bones, 177 



ZONA pellucida of ovum, 76 
radiata, 76 



OCT -0 I3'sl 



